How leveraging technology helps patients maximize the benefits of chronic care management


Chronic diseases are the leading causes of illness, disability, and death in the United States, according to the Centers for Disease Control and Prevention. They are also the leading drivers of $4.1 trillion in annual healthcare costs. These diseases affect six in 10 American adults, and four in 10 adults have two or more of them. As healthcare organizations—particularly rural health clinics and federally qualified health centers—strive to provide value-based care, chronic care management (CCM) is one way to lower costs while simultaneously improving outcomes.


CCM makes tremendous improvements in the health and quality of life of chronically ill patients. However, to truly maximize the benefits of CCM, healthcare organizations must do two things:


  1. Find ways to proactively identify patients who qualify for CCM.
  2. Help patients understand the value of CCM.


What’s the key to success?


Technology. Manual processes and workflows simply aren’t effective or scalable in any way. Instead, consider the following ways in which various technologies help patients and providers derive maximum benefit from CCM:


  1. Patient identification. One of the biggest barriers to CCM is that enrollment often only comes during an office visit. Technology helps providers take a targeted approach without having to wait for patients to be present for an appointment. Unfortunately, many chronically ill patients may not routinely see their doctor. This means there are few opportunities to engage these patients in meaningful ways. The good news is that technology creates an efficient way for providers to easily identify patients who qualify for CCM.


  1. Patient education. Once providers identify patients who are eligible for CCM, they can leverage the patient portal to open lines of communication. For example, providers can use the portal to provide an electronic copy of the patient-centered care plan, deliver personalized educational resources and automated education interventions, and promote greater collaboration and coordination.


Providers can also use the portal to answer common questions about CCM, such as:


  • What are the benefits of CCM? More specifically, how does it help patients better manage their care, achieve their health-related goals, and even avoid going to the hospital?
  • What’s involved in CCM? Explain to patients how a dedicated care team will review their records and contact them frequently to check in and make sure they stay on track. That care team will also work closely with specialists to coordinate care and promote optimal health and wellness.
  • How much does CCM cost? Let patients know they may incur a monthly fee for CCM.


  1. Care gap closure. At the point of care during a CCM encounter, providers can leverage technology to identify and address care gaps, thereby promoting the right care for the right patient at the right time.


  1. Ongoing patient engagement. Remote patient monitoring (RMP) is a great way to keep tabs on patients enrolled in CCM and promote ongoing engagement. RPM uses FDA-cleared medical devices to monitor vital signs like blood pressure, weight, blood glucose, and lung capacity. However, keep in mind that while all CCM patients are eligible to receive RPM services, not all RPM patients are eligible for CCM services.


About DignifiHealth

DignifiHealth partners with health systems on value-based healthcare, chronic disease management, care gap closure, and more to create exceptional patient and health system results. To learn more, visit