From CMS: Why Is This Initiative Important? With millions of Americans living with a chronic health

https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/ccm/hcpresources.html

Connected Care: The Chronic Care Management Resource

The Connected Care initiative provides resources and tools that can help health care professionals learn how to implement chronic care management (CCM) and receive payment for providing these services.

Chronic care management is care coordination services done outside of the regular office visit for patients with multiple (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 non-face-to-face and allows eligible practitioners to bill for at least 20 minutes or more of care coordination services per month.

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