Chronic Care Management (99490): Support and Aid for Caregivers

An estimated 43.5 million adults in the United States have reported providing unpaid care to an adult or a child in the prior 12 months, with over three quarters of these caregivers providing care for an adult age 50 or older (1). Many people living with chronic illness could not live independently without caregivers (2). Caregivers function as advocates for their loved ones and provide physical, emotional, and financial support (2). Yet, who provides support and aid for caregivers?

The Need for Support and Aid for Caregivers

Although the caregiver role consists of comprehensive management of a loved one’s care, caregivers often fall short regarding their own well-being. When asked about the impact that caregiving has had on their health, 22 percent of caregivers report feeling their health had declined as a result of caregiving (1). For this reason, CCM coordinators should acknowledge caregiver strain and work to alleviate the associated stress.  Chronic Care Management should provide patients, as well as their caregivers, with individualized support necessary to improve health outcomes.

Recognize Caregiver Strain

About 25 percent of caregivers provide 41 or more hours of care per week (1). Caregivers assisting Chronic Care Management patients may be responsible for the following duties:

  • Transportation
  • Medication management
  • Activities of daily living
  • Provider communication
  • Home maintenance

In spite of these responsibilities, caregivers often lack any training, recognition, or support, and rarely obtain financial reimbursement (2). During communication with a CCM patient’s caregiver, a coordinator may learn of the following hardships:

  • Strain from financial barriers (e.g. food supplements, utilities, medication costs)
  • Need of medical equipment/supplies
  • Misunderstanding of provider directions
  • Lack of nursing care instructions
  • Stress of managing multiple chronic conditions

To alleviate the above concerns, it is imperative that CCM coordinators provide impactful interventions. When working with caregivers, coordinators should be compassionate and assess for assistance needs. Caregivers may need individual support for their own concerns and lack of resources, as well as patient-specific support in relation to each chronic condition, care plan, and circumstance. They should be provided with resources to not only better improve the CCM patient’s care, but to enable the caregiver to best revive his or her health.

Connect Caregivers to Resources

Despite the amount of time caregivers spend providing care, only 34 percent have been able to make modifications to their loved one’s home (1). Even fewer have requested financial assistance (28 percent), used transportation services (23 percent), or initiated respite services (15 percent) for their loved one (1). Because caregivers may struggle to connect with resources, Chronic Care Management coordinators should be accessible 24/7 as a direct link to local assistance options. CCM coordinators may be able to point caregivers towards resources including, but not limited to, the following:

  • Respite services
  • Home health agencies
  • Senior activity centers
  • Health department and hospital patient teaching classes
  • Food supplement programs
  • Low income benefits
  • Support groups
  • Medication assistance programs
  • Community closet agencies


These assistance options can provide much relief from the numerous demands that CCM patients place on caregivers

Additionally, CCM coordinators may help reduce caregiver stress by:

  • Handling communication with health care professionals, appointment compliance, and transportation assistance
  • Assisting the caregiver with applying for benefit programs
  • Providing education on nursing care skills and medication management
  • Helping the caregiver locate local classes and online materials about chronic condition care improvement


The Chronic Care Management program’s support and resources should empower caregivers to provide optimum care to their loved ones while preserving their own well-being.  These components of CCM care improve patient satisfaction, encourage healthier lifestyles, and, in turn, reduce caregiver stress.


  1. National Alliance for Caregiving. Caregiving in the U.S. . s.l. : Public Policy Institute , 2015.
  2. Arnold Goldberg, MD and Kim Salloway Rickler, MSW. The Role of Family Caregivers for People with Chronic Illness. Pawtucket,RI : Department of Family Medicine Memorial Hospital of Rhode Island , 2011.




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