Chronic Care Management and Connected Care

A young medical woman leaning forward and smiling to an elderly man

An estimated 117 million adults have one or more chronic health conditions, and one in four adults have two or more chronic health conditions. Through the Connected Care campaign, the CMS Office of Minority Health and the Federal Office of Rural Health Policy at the Health Resources & Services Administration will raise awareness of the benefits of CCM for patients with multiple chronic conditions and provide health care professionals with resources to implement CCM.

CCM is care coordination services done outside of the regular office visit for patients with two or more chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. These services are typically not face-to-face and allow eligible practitioners to bill for at least 20 minutes or more of care coordination services per month.

With millions of Americans living with a chronic health condition, your support is critical to raising awareness about the benefits of CCM services. By offering CCM services, health care professionals can deliver the coordinated care their patients need and help patients stay on track by getting support between visits.

A mobile phone with a doctor on the line

“Connecting the Dots” Animated Video for Patients

Use this animated video to help explain the benefits of CCM services to your patients.

Health Care Professionals Eligible to Bill for CCM

Physicians and the following health care professionals can bill for CCM services: physician assistants, clinical nurse specialists, nurse practitioners, and certified nurse midwives. Federally Qualified Health Centers, Rural Health Clinics, and Critical Access Hospitals can also bill for CCM services. Only one practitioner per patient may be paid for CCM services for a given calendar month.

Resources for You 

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CCM Connected Care Toolkit (PDF)

There are many ways to spread the word about the benefits of CCM. Download the Connected CareToolkit (PDF) to find resources, such as sample newsletter text, social media assets, and web badges, you can use to raise awareness about the importance of CCM services for Medicare and dual eligible patients managing multiple chronic conditions.

A smiling black female doctor

Connected Care Physician Testimonial About Chronic Care Management

Watch and share one doctor’s testimonial about how offering CCM helps her Medicare patients and practice in rural North Carolina.

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Connected Care Postcard for Health Care Professionals (PDF)

Designed for health care professionals, this postcard explains CCM and its benefits.

A group of 5 medical people sitting in a circle

Health Care Professional Presentation (PDF)

Review the presentation to learn about the Connected Care public education campaign and start a successful program in your practice.

A folder of documents

CMS Care Management

Visit the CMS Care Management page to find CCM resources, including fact sheets, FAQs, and data on chronic conditions in Medicare.

Resources for Patients 

A mobile phone with a doctor on the line

"Connecting the Dots" Animated Video for Patients (PDF)

Watch “Connecting the Dots" Animated Video for Patients. Available in English and Spanish, this resource can be used to help explain the benefits of CCM services to your patients.

This resource is available in two languages:

English (PDF)

Spanish/Español (PDF)

Graphic of postcard in front of orange background

Connected Care Poster for Patients (PDF)

Use this poster in your office or waiting room to promote the benefits of CCM to patients.

This resource is available in two languages:

English (PDF)

Spanish / Español (PDF)


a graphic of a postcard

Connected Care Postcard for Patients (PDF)

CCM services may include personalized assistance from a dedicated health care professional, 24/7 emergency access to a health care professional, and coordination of care between your pharmacy, specialists, testing centers, and hospitals. Download this postcard to learn the benefits of CCM.

This resource is available in eight languages:

English (PDF)

Arabic / ال عرب ية (PDF)

Chinese / 中文 (PDF)

Haitian Creole / Kreyòl Ayisyen (PDF)

Korean / 한국어 (PDF)

Russian / Русский (PDF)

Spanish / Español (PDF)

Vietnamese / TIẾNG VIỆT (PDF)

Resources for Rural Health Clinics and Federally Qualified Health Centers

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Chronic Care Management Services in Rural Health Clinics and Federally Qualified Health Centers Frequently Asked Questions (PDF)

This FAQ sheet answers billing questions for Rural Health Clinics and Federally Qualified Health Centers.

Order Printed Materials

Printed copies of the Connected Care postcards and posters can be ordered at no cost to your organization. Visit our Product Ordering Instructions page to learn how to place an order.

Page Last Modified:
03/30/2023 11:32 AM