CCM program continuity depends on how a care team carries a patient’s needs forward. For chronic care management Medicare services, a medication concern raised during one conversation should inform the next. A practitioner’s decision should reach the patient and the care navigator responsible for follow-up. An unresolved problem should remain visible when a new month begins.
That connection can be difficult to see in a program measured mainly through enrollment, completed contacts and recorded minutes. Those figures describe activity. Understanding continuity requires following what happened to the patient’s care over time.
Two independent analyses of Medicare claims land on the same number. A CMS-commissioned evaluation found 19% of CCM recipients had only one month of service recorded during 2015 and 2016. [2] A national study using a 5% sample of fee-for-service beneficiaries aged 65 and older found nearly one in five did not continue past their initial service across 2015 to 2019. [1] Different datasets, different windows, the same result: roughly one in five CCM patients never reaches a second month.
These findings establish a reason to examine continuing participation. They do not explain every departure or show that every missing claim represents a failure of care. Practices need to understand both whether patients continue and what the continuing service achieves for them.
Each CCM month should build on what the care team already knows, what the patient has agreed and what remains unresolved.
What makes monthly CCM care continuous?
Chronic care management services are continuous when each contact carries forward an agreed concern, action and owner for follow-up. Vivo Care supports this work through a shared platform that aligns patient engagement, program oversight and compliance support with the practice’s staffing model, while keeping practitioner oversight in view. The result is ongoing CCM patient engagement with a clear operational home.
The first article in this series examined the care pathway behind a defensible CCM claim. The second followed the operating steps between potential eligibility and CCM enrollment. Once a patient is receiving care, the next question is how that work develops across successive months.
CMS describes continuity through regular contact with a designated care-team member, access for urgent needs and communication with the practice. Its CCM guidance also includes revising and monitoring the comprehensive care plan as appropriate. [3]
Putting those elements into practice requires a connection between past decisions and current work. This is the basis of continuous, collaborative patient care: before contacting a patient, the care team should be able to identify the previous concern, the action that followed and anything still requiring attention. The conversation can then test whether that action helped and whether the patient’s circumstances have changed.
A useful review question is whether the latest contact would have been different if the previous month’s work had never occurred.
Following one patient from month two to month six
The following fictional example illustrates an operating approach. It is not a Vivo Care patient case or evidence of a clinical outcome. The patient has hypertension and type 2 diabetes and has already entered CCM.
The months are snapshots of continuing care, not a prescribed contact schedule. Concerns requiring assessment or action are addressed according to clinical urgency, without waiting for the next monthly contact.
The workflow below is the same under either delivery model. Under Managed Clinical, Vivo Care care navigators perform the contacts and carry the open items. Under Practice-Managed, the practice’s own staff do that work on the same platform, with the same record of what was agreed and what is still open.
Month two: identify the barrier behind the concern
During a conversation about managing medications at home, the patient explains that collecting refills has become difficult since a family member’s work schedule changed. The care team reviews the immediate implications and involves the practitioner where needed.
The continuing task is specific: establish an appropriate way for the patient to obtain medication and check that it works. With the patient’s agreement, the care navigator helps explore pharmacy arrangements and records who will confirm the next step and when.
A general note about adherence would leave the next care navigator uncertain about what to do. Recording the collection barrier and agreed action gives subsequent contacts a clear starting point.
Month three: check whether the agreed action worked
The care navigator returns to the refill arrangement. Was the medication obtained? Is the arrangement workable? Has another difficulty appeared?
The patient confirms that collection is now arranged but is uncertain about instructions received at a recent appointment. The care navigator brings that question to the appropriate practitioner and follows through on clarification.
To check understanding, the patient is invited to explain the clarified instructions in their own words. AHRQ’s teach-back guidance recommends this approach as a way to assess how clearly information has been explained, with further explanation when needed. [4]
The next follow-up now reflects both the resolved collection problem and the question about understanding. The care plan can preserve that history without treating an old barrier as permanently settled.
Month four: carry the practitioner’s decision into follow-up
At a subsequent review, the practitioner changes part of the treatment plan. The care team receives the updated instructions and identifies what needs to be checked after the change.
The care navigator confirms that the patient has received the instructions and routes questions back to the practitioner. Follow-up addresses the agreed points, with concerns escalated through the practice’s clinical process.
The connection is complete when the next contact reflects the practitioner’s decision. A response sitting in an inbox cannot guide a conversation unless the responsible care navigator has seen it and incorporated the required action.
CMS places clinical-staff CCM under the billing practitioner’s overall direction and control. [3] In this example, the practitioner makes treatment decisions while the care team supports communication and follow-through within its scope.
Month five: preserve the relationship through a disruption
The usual care navigator is absent when the patient misses an arranged contact. The covering care navigator can see the recent treatment change, agreed follow-up and preferred contact arrangements.
That context helps the care team decide the appropriate next action under the practice’s outreach and escalation procedures. It also avoids treating the missed contact as an isolated scheduling event.
When contact resumes, the care team checks what caused the interruption and whether communication arrangements need to change. Any unresolved concern remains assigned to a responsible care navigator.
Coverage has preserved continuity when another care navigator can continue the work with an accurate understanding of the patient’s situation.
Month six: review what still requires support
The review returns to the patient’s priorities. Is obtaining medication still manageable? Are the current instructions understood? What does the patient now find difficult about managing care between appointments?
Some tasks may be complete. Others may need a different approach or further practitioner input. The care team records that distinction and agrees the next steps with the patient.
This review does not require a new intervention every month. A stable situation can still merit monitoring and support. The purpose is to establish whether the existing plan remains appropriate and where further work is needed.
Who owns an issue until it is resolved?
The example depends on responsibility continuing after an action has been initiated. Contacting a pharmacy, sending a question to a practitioner or arranging an appointment can each leave further work outstanding.
A practical workflow should identify who will check the response and what happens if it does not arrive within the agreed timeframe. When responsibility changes, the receiving care navigator should acknowledge the outstanding task and have enough context to continue it.
For an escalation, the record should distinguish the concern being sent, the practitioner reviewing it, the decision being communicated and the required follow-up being completed. Those are separate events. Recording the first does not establish the last.
This is the accountability question introduced in part one: can the practice follow a concern through to its disposition, including any continuing monitoring that has been agreed? The CCM requirements provide a formal frame for that operational question.
What research can tell us about the value of continuing care
Research provides a reason to examine how CCM is delivered, while leaving important questions about which operating practices produce results.
A 2023 Louisiana study compared 282 older patients with diabetes who received non-face-to-face chronic care management services with 26,759 eligible patients who did not. Using an adjusted observational analysis, the researchers found associations with fewer inpatient and emergency-department visits and more outpatient visits. [5]
The study supports examining care management’s potential role in how patients use healthcare. It does not establish that the workflow illustrated here causes those changes, or that more contacts necessarily produce better outcomes. Practices still need to assess the quality of their own follow-through and the experience of their patients.
How to measure CCM continuity
Retention is one useful measure, but it becomes more informative when the practice defines what it counts and examines reasons for interruptions. A patient remaining on an enrollment list, having a documented interaction and receiving a billed service are different observations.
The following are suggested operating measures for local review in both Practice-Managed and Managed Clinical programs, rather than CMS performance thresholds or validated predictors of outcomes.
| Review area | Suggested measure | What to examine |
|---|---|---|
| Agreed follow-up | Actions completed by their agreed due date as a proportion of actions due | Which tasks became overdue and why |
| Clinical escalation | Outstanding concerns by urgency, age and current stage | Where practitioner review, communication or follow-up is delayed |
| Connection between contacts | Sampled records showing follow-up on a previously agreed action | Whether the next contact uses the earlier care history |
| Continuing participation | Participation at defined intervals among patients who started in the same period | The definition of participation and reasons for pauses or exits |
For a three- or six-month participation review, use groups with sufficient follow-up time. Report deaths, transfers, changes in eligibility and patient decisions separately so that a single percentage does not conceal different circumstances.
Pair these measures with patient feedback. Asking whether the care team followed up on a concern, and whether the patient knows the next step, can expose gaps that a completed-contact count misses.
For the broader care-planning, documentation and service requirements, read the 2026 Chronic Care Management Guide.
For a practical monthly review, use the CCM Monthly Audit Checklist.
Review one care issue across consecutive months
A practical starting point is to trace one issue through several months of a patient’s record. Choose an issue that required follow-up, such as difficulty obtaining medication or a question referred to the practitioner.
- What did the patient need help with, and what action was agreed?
- Who remained responsible while that action was outstanding?
- Where is the response or decision recorded?
- How did the next contact check what happened?
- What remains unresolved, and does the current plan reflect it?
If the sequence breaks, identify where the workflow stopped carrying the issue forward. The response may involve clearer task ownership, a better handover or a way to flag overdue follow-up. Review a range of cases before drawing conclusions about the whole program.
Build on the care already delivered
The refill concern in the example becomes useful knowledge for the care team. It shapes the next conversation, remains available during staff cover and helps the practice understand what the patient needs months later.
That is the practical aim of CCM continuity: care that develops with the patient’s circumstances and preserves responsibility for unfinished work.
To review how your program connects patient contacts, practitioner decisions and continuing follow-up, schedule a CCM consultation with Vivo Care.
Frequently asked questions
What makes CCM continuous rather than repetitive?
Continuity means each contact uses the relevant history and follows through on earlier decisions. Repeated questions can be clinically appropriate, but the care team should know what was agreed previously and whether it still meets the patient’s needs.
Does the same care navigator need to handle every contact?
A familiar care navigator can support an ongoing relationship, and CMS describes regular contact with a designated care-team member. [3] Under Managed Clinical, Vivo Care provides coverage through its care navigators; under Practice-Managed, the practice’s own staff do the work. In either model, coverage should preserve continuity through accessible records, clear handovers and responsibility for outstanding work.
When is a clinical escalation complete?
For operational review, distinguish referral of the concern from its clinical disposition. Completion should reflect the practitioner’s response and any required communication or follow-up. If further monitoring is needed, assign that work explicitly.
Does a missing CCM claim mean the patient disengaged?
A missing claim alone cannot establish the reason. Review the clinical record, service activity and patient circumstances before categorizing an interruption. Claims-based participation should be distinguished from patient engagement.
Which measures should a practice review first?
Start with overdue follow-up, unresolved escalations and whether subsequent contacts address previous actions. Add participation over defined periods and reasons for leaving. Together, these provide a more useful starting point than a monthly enrollment total alone.
References
- Jang J, McCarthy EP, Olivieri-Mui B, et al. Use of chronic care management service among Medicare beneficiaries in 2015–2019. Journal of the American Geriatrics Society. 2024;72(9):2730–2737. doi:10.1111/jgs.19066.
- Schurrer J, O’Malley AS, Wilson C, McCall N, Jain N. Evaluation of the Diffusion and Impact of the Chronic Care Management Services: Final Report. Mathematica Policy Research for CMS. November 2, 2017. Table III.1.
- Centers for Medicare & Medicaid Services. Chronic Care Management Services. MLN909188. June 2025. Pages 4, 6 and 7.
- Agency for Healthcare Research and Quality. Use the Teach-Back Method: Tool 5. Health Literacy Universal Precautions Toolkit, 3rd Edition.
- Stoecker C, Nauman E, Bazzano AN, et al. Non–Face-to-Face Care Management and Service Utilization in Patients With Diabetes. The American Journal of Managed Care. 2023;29(8):417–422. doi:10.37765/ajmc.2023.89407.