Why Chronic Care Management Is Essential in Skilled Nursing
Chronic Care Management: The Essential Explainer for Skilled Nursing and Long-Term Care
The resident profile in skilled nursing and long-term care is becoming more acute. Stays are becoming longer, and the needs of residents are more complex, as 70% also have two or more chronic conditions. The challenge of managing chronic conditions for longer durations is compounded by operational realities: value-based payment models and resource constraints.
In response to the growing acuity of residents, chronic care management (CCM) has become an increasingly effective tool for improving care outcomes by maintaining greater continuity across specialties in skilled nursing and long-term care.
CCM has been shown to reduce complications, improve care quality, and alleviate staff burden, while providing adequate reimbursement for facility operators.
1. Proactive Care Reduces Avoidable Hospitalizations
As the majority of residents in SNFs have multiple chronic conditions–often complicated by behavioral health needs–close coordination is required between primary care providers, specialists, therapists, and facility nursing staff.
Small gaps in communication can lead to complications requiring rehospitalization. Chronic care management provides a structure and cadence that enable care delivery, helping facilities become proactive rather than reactive:
- Regular, cross-team reviews that catch early signs of decline
- Medication reviews to reduce polypharmacy risks
- Actively managed care plans that improve clinician collaboration
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Chronic care management is a systemic approach that becomes the connective tissue that keeps residents stable and on-site.
Fewer adverse events mean healthier residents, supporting resident and family satisfaction, and stronger alignment with value-based care standards.
2. Enhanced Oversight without Increasing Staff Burden
Workforce shortages are an ongoing issue in skilled nursing and long-term care. Nurses are stretched thin, physicians are on tight schedules, and administrators are juggling compliance, staffing, and operations. A CCM program layers support around the existing care team.
With a modern CCM infrastructure or external partner, facilities gain:
- A dedicated clinical extension focused solely on proactive care
- Documentation and coordination that meet CMS standards
- Improved handoffs between facility clinicians and off-site providers
For providers participating in ACOs or shared-savings models, a strong chronic care management program also supports quality measures tied to readmissions, chronic disease control, and care coordination.
3. A Sustainable Approach Supported by Reimbursement
CMS reimburses Chronic Care Management under distinct codes designed to compensate providers for the monthly work of coordinating care for residents with complex needs.
By integrating CCM, facilities can:
- Generate recurring monthly revenue per qualifying resident
- Improve financial resilience without increasing workloads or hiring new staff
- Reinvest in clinical quality initiatives
4. Better Resident and Family Experience
Families increasingly expect continuous communication and proactive care. Chronic care management smooths out the complexity of having multiple specialists participating in an individual's recovery. Multiple touchpoints are synthesized through a single point of contact, reducing complexity for caregivers.
Facilities see benefits such as:
- Consistent monthly communication
- Improved trust due to structured monitoring
- Enhanced resident quality of life
In an era where reviews and family satisfaction influence referral patterns, CCM becomes a powerful differentiator.
Lumina Care’s Chronic Care Management Program: A Strategic Advantage for Better Outcomes and Stronger Operations
Chronic care management is more than a reimbursement model. It’s a strategic approach to care delivery that streamlines collaboration between specialists, helping improve care quality by ensuring better communication and coordination for residents with multiple conditions.
Lumina Care’s dedicated CCM program is a robust, remote clinical service that enables better care delivery. Our clinical and operations experts follow a detailed onboarding plan with each patient and provide ongoing, real-time updates.
With a proactive approach to person-centered care, Lumina Care is helping SNFs and long-term care operators move from resource-constrained to empowered providers.
Lumina Care delivers continuous, coordinated care by connecting providers nationwide. At all hours and across settings, we integrate directly with your team to reduce complications, improve outcomes, and support around-the-clock clinical care without adding to your workload.