Chronic Care Management Services for Complex Diabetes Management: a Practical Overview

Formalized chronic care management has the potential to improve the quality and cost-effectiveness of complex diabetes management in adults, but has historically not been sustainably supported by health care systems. This review discusses the application of the chronic care model in the care of complex diabetes and its translation in the current reimbursement structure designed by Centers for Medicare and Medicaid Services (CMS).

Following the introduction of Wagner's Chronic Care Model (CCM) in the late 1990s, evidence gathered over the past 2 decades has supported the shift in focus of health care systems from acute to chronic disease management and proactive care. Acknowledging evidence and potential for improved cost-effectiveness, in 2015, Medicare began reimbursing for chronic care management services (CCMS) for patients with multiple chronic conditions. The CCMS billing codes allow a program to be reimbursed for up to 90 min per month spent by clinical staff performing interim care within a comprehensive care plan. Recent data from local and global programs support the application of formalized CCM in diabetes management. Although reimbursement models for CCM have been designed for use in primary care, the challenges of the reimbursement model has opened the door for specialty areas focused on multimorbidity care such as diabetes care to explore this approach. With the broader availability of remote glucose monitoring and telemedicine, a strategy that combines goal-oriented care and telehealth solutions appears to be most effective in diabetes CCM care. Despite widespread acceptance of the chronic care model of care, there remain significant barriers to its incorporation into standard practice.