The Importance of Chronic Care Management

Living with a chronic health condition can be challenging, but it is important to remember that you are not alone. There is help available. In fact, chronic care management is a valuable and effective option to help people with ongoing health challenges stay healthy and manage their symptoms.

Read on to learn more about chronic care management and how The Advanced Care Group (ACG) can help you or a loved one manage chronic illness.

What is chronic illness?

A chronic illness is a long-term health condition that can be caused by a variety of factors, including genetics, lifestyle choices, and environmental factors. Chronic illnesses are often characterized by symptoms that persist for more than three months and may require ongoing medical attention or limit activities of daily living.

Some of the most common chronic health conditions include:

  • Heart disease
  • Stroke
  • Diabetes
  • Chronic obstructive pulmonary disease (COPD)
  • Alzheimer’s disease
  • Arthritis
  • Asthma
  • Mental illness
  • Kidney disease

Unfortunately, there is no cure for most chronic health conditions, but there are treatments that can help manage the symptoms and improve quality of life.

What is chronic care management?

Chronic care management (CCM) is an approach to care that helps people with chronic diseases stay healthy and manage their symptoms. CCM involves a team of healthcare professionals who work together to provide coordinated care. The team may include a doctor, nurse, pharmacist, social worker, and other healthcare providers

According to, “CCM includes a comprehensive care plan that lists your health problems and goals, other providers, medications, community services you have and need, and other information about your health. It also elaborates on the care you need and how your providers will coordinate it.”

What is the goal of palliative care?

The main goal of palliative care is to alleviate pain and manage symptoms while improving the patient’s overall well-being and quality of life. Additionally, it includes identifying patients’ goals for their care, and providing emotional and spiritual support while considering the whole patient and their personal situation. It can also be provided alongside other treatments, such as surgery, chemotherapy, or radiation therapy, as well as at any stage of illness, from diagnosis to the end of life.

How can chronic care management help patients?

The goal of CCM is to improve the health outcomes of people with chronic diseases. This can be achieved by helping people to:

  • Set and achieve health goals: This involves working with the patient to develop a personalized care plan that includes specific goals, such as lowering blood pressure or losing weight.
  • Take their medications correctly: This includes ensuring that the patient understands how to take their medications, when to take them, and what side effects to watch for.
  • Manage their symptoms: This includes helping the patient to manage their symptoms, such as pain or fatigue.
  • Make healthy lifestyle changes: This includes helping the patient to make changes to their diet, exercise, smoking habits, etc.
  • Access the care they need: This includes ensuring that the patient has access to the care they need, such as doctor’s appointments, lab tests, and medications.

What are the benefits of chronic care management?

CCM can help improve the quality of life for patients and caregivers. Here are a few additional benefits:

  • Improved health outcomes: CCM has been shown to improve health outcomes for people with chronic diseases. Studies have shown that CCM can reduce hospitalizations, improve quality of life, and lower healthcare costs.
  • Increased patient satisfaction: Patients who participate in CCM programs often report higher levels of satisfaction with their care. This is likely because CCM provides patients with more personalized care and support.
  • Reduced healthcare costs: CCM can help to reduce healthcare costs by preventing hospitalizations and emergency room visits. Studies have shown that CCM can save money for both patients and payers.
  • Improved patient self-management and adherence to treatment plans: CCM can help patients to learn how to manage their own chronic conditions. Additionally, it can help patients stick to their established treatment plan.
  • Increased access to care: CCM can help patients to get the care they need when they need it. This can help to prevent complications and improve quality of life.
  • Additional benefits: CCM can also help:
    • reduce stress and anxiety.
    • improve communication between patients and healthcare providers.
    • patients to feel more in control of their health.
    • patients to make lifestyle changes that improve their health.

What does chronic care management involve?

The services available with CCM vary depending on the program and resources available, but some of the most common services include:

  • Annual wellness visits and checkups
  • Symptom and medication management
  • Coordination of information and referrals between your medical team
  • Health education
  • Behavioral health support
  • Nutrition and exercise counseling
  • Social support, financial and transportation assistance, and interpreter services
  • And much more

In what settings can chronic care management be delivered?

CCM can be delivered in a variety of settings. The best setting for CCM will vary depending on the needs of the patient and the resources available. Some of these settings include:

Primary Care

This is the most common setting for CCM. Primary care doctors are often the first point of contact for people with chronic diseases, and they can play a key role in coordinating care and providing education and support.


CCM is sometimes offered in hospitals to help patients transition to home care. Hospitals can provide a comprehensive range of services, including medical care, rehabilitation, and social services.

Community Health Centers

These centers provide healthcare services to low-income and underserved populations. Community health centers often have a strong focus on preventive care and chronic disease management.

Home Health Care Providers

These providers care for patients in their homes. Home health providers can offer a variety of services, including nursing care, physical therapy, and social services.


This is a newer way to deliver CCM, and it allows patients to receive care from a distance. Telehealth can be a convenient option for patients who live in rural areas or who have difficulty getting to appointments.

Nursing Homes

Nursing homes provide long-term care to people who need assistance with daily living. CCM can help nursing home residents to manage their chronic conditions and stay healthy.

Skilled Nursing Facilities (SNFs)

SNFs provide short-term, post-acute care to people who need rehabilitation after an illness or injury. They typically offer a higher level of care than nursing homes, and may also offer services like physical therapy, occupational therapy, speech therapy, wound care, IV therapy

Rehabilitation Centers

Rehabilitation centers provide services to help people recover from injuries or illnesses. CCM can help rehabilitation center patients to manage their chronic conditions and prevent complications.

Mental Health Clinics

Mental health clinics provide services to people with mental health conditions. CCM can help mental health clinic patients to manage their conditions and improve their quality of life.

Specialty Care Clinics

Specialty care clinics provide services to people with specific chronic conditions, such as diabetes or heart disease. CCM can help specialty care clinic patients to manage their conditions and get the care they need.

Chronic Care Management at ACG

Our team at ACG is proud to provide exceptional chronic care management services. We work closely with patients to create comprehensive care plans tailored to their specific needs, goals, and situation. Additionally, we are committed to giving patients the care and support they need to help manage their chronic condition and live as healthfully as possible.

If you are considering chronic care management for yourself or a loved one, contact us at 615.941.8550.

About The Advanced Care Group 

The Advanced Care Group (ACG) is a healthcare company based in Middle TN that specializes in providing full-service medical management for patients with acute and chronic conditions in both the home and the skilled nursing facility setting. Our home-based (in-home) medical care provides support for patients with complex medical conditions like a chronic or serious illness, injury, disability, or following a major surgery. Our in-patient skilled nursing services include acute and chronic disease management with a focus on transitioning the patient from hospital to home or long-term disease/distressful symptom management for long-term care patients.


This blog provides general information and discussions about health and related subjects. The information and other content provided in this blog, or in any linked materials, are not intended and should not be construed as medical advice, nor is the information a substitute for professional medical expertise or treatment.

If you or any other person has a medical concern, you should consult with your healthcare provider or seek other professional medical treatment. Never disregard professional medical advice or delay in seeking it because of something read on this blog or in any linked materials. If you think you may have a medical emergency, call your doctor or emergency services immediately.

The opinions and views expressed on this blog and website have no relation to those of any academic, hospital, health practice, or other institution.

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