Multi-State ACOs Chronic Care Management Overview

This document is a guide on Chronic Care Management (CCM) within multi-state Accountable Care Organizations (ACOs) and its significance in value-based payment models such as the MSSP model. It outlines how CCM programs assist providers in managing patients with multiple chronic conditions, thereby promoting quality care, preventing treatment gaps, and enhancing patient health outcomes. The document presents a case study of a multi-state ACO with nearly 20,000 attributed Medicare lives, demonstrating the effectiveness of CCM through lower inpatient admission rates and substantial cost savings. It details the technology used, specifically Garage's population health platform, Bridge, which identifies eligible patients and supports care coordination through the Ignite app. The outcome section highlights the benefits experienced by participating practices, including improved patient interactions and overall healthcare cost reductions. The guide emphasizes the importance of CCM services in driving better patient outcomes and increasing satisfaction while reducing costs.