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Chronic care management (CCM) is complicated — even starting with “what does it mean?” It’s more than just industry jargon. Chronic care management is the medical management of patients with chronic diseases and the education surrounding these diseases by healthcare professionals.

However, to be educated on CCM, there are many other industry terms you should know. That’s why we’ve created a glossary of terms related to chronic care management so you’re never left scratching your head.

Contact us if you’re ready to discuss your chronic care management strategy


Care Coordination: The organization of a patient’s care activities (testing, procedures, visits, etc.) between two or more individuals with the goal of delivering the right care activity at the right time.

Care management platform: A care management platform is the administration tool used to handle the range of medical activities, treatments, diagnostic tools, and care to improve the health of, or manage, individual patients.

Digital health: Digital health is the union of the digital age and health. This includes healthcare, lifestyle, and society. Digital health enables individuals and their providers to better track — and thus manage — health, which leads to longer and more productive lives.

Fee-for-service (FFS): Fee-for-service is a healthcare payment model where clinicians are paid for performing a service for a patient rather than for the quality of that service. This fosters an incentive for quantity over quality.

Gaps of Care: The difference between the care activities that are recommended for a patient, and what is actually provided to that patient.

MIPS: The Merit-Based Incentive Payment System is under Medicare’s Quality Payment Program. MIPS is one of two tracks that applies to Medicare Part B partners which pays providers according to performance.

Predictive modeling: Predictive modeling is the use of extensive data to forecast an outcome — in this case outcomes related to patients. The models each have variables known to influence an outcome. The more data is collected, the more accurate future events can be predicted.

Risk stratification: Risk stratification is using predictive modeling to figure out which patients are likely to be, or are, high-risk individuals. Healthcare professionals then prioritize their care in order to prevent the poor outcomes associated with these high-risk individuals.

Shared care plan: A shared care plan is designed around a patient and acts as a guide for communication between all the care team members — this includes the patient and providers. Instead of having many plans for a single patient, there is one cohesive plan for the patient.

Transitions of Care: A transition of care is when a patient moves from one care setting to another. For example: when a patient moves from a hospital to a rehabilitation facility.

Value-based payments: This is also referred to as “pay for performance.” Instead of paying clinicians by how many services they perform, they are paid for hitting certain performance marks such as readmission rates. This promotes care that is quality over quantity.


Now that you’re equipped with a glossary of chronic management terms, you should see how much additional revenue you’re missing out on. Check out our revenue calculator to get an estimate and contact us to set up a free consultation.