Chronic Care Management (99490): Three Tools to Enhance Diabetes Management

According to the Centers for Medicare and Medicaid (CMS), 32% of Medicare spending is attributed to the diabetes population (1). More than 29 million Americans have diabetes; one in four people with diabetes does not know he or she has it (2). Although some risk factors for diabetes mellitus such as race and family history are changeless, other risk factors (e.g. obesity, hypertension, inactivity) may be impacted through informed diabetes management. Chronic Care Management patients as well as their family members and/or caregivers should have a clear, individualized care plan geared towards controlling the patient’s diabetes mellitus. Chronic Care Management should provide patients with methods to control blood glucose levels, prevent complications or other conditions, and locate resources for expenses associated with diabetes mellitus.

Control Blood Glucose Levels with CCM

There is no cure for diabetes, but it can be managed (3). CCM coordinators should promote medication adherence, but also engage CCM patients with additional ways to control blood glucose levels. More than 1 in 3 U.S. adults – have prediabetes, where their blood sugar levels are higher than normal but not high enough to be classified as type 2 diabetes (2).  Without weight loss and moderate physical activity, 15 percent to 30 percent of people with prediabetes will develop type 2 diabetes within five years (2). CCM coordinators should provide patients with appropriate education (e.g. video tutorials, local diabetes classes, reference materials online) pertaining to diabetes mellitus so that efforts to control levels will be well-informed and consistent.  Chronic Care Management patients should receive assistance with implementing lifestyle changes that can improve their daily lives and experiences associated with prediabetes and/or diabetes mellitus management. Typical interventions initiated for positive CCM progress for prediabetes/diabetes patients include:

  • Maintain a blood glucose log
  • Set a weight loss goal
  • Prepare healthy meal options
  • Avoid a sedentary lifestyle
  • Take medications as directed
  • Schedule routine exercise
  • Monitor eating habits

Coordinators should assist with the aforementioned tasks as well as other patient-specific needs when necessary. Chronic Care Management patients with prediabetes or diabetes should receive 24/7 support for any emotional feelings triggered by implementing these changes. CCM coordinators should encourage patients, acknowledge their efforts, and help prevent/delay diabetes complications so they may embrace long and healthful lives.

Prevent Diabetes Complications or Related Conditions

CCM patients should be made aware of long-term complications that can develop gradually and are associated with poor management of diabetes. At least 68 percent of people age 65 or older with diabetes die from some form of heart disease; and 16% die of stroke (4). The American Heart Association considers diabetes to be one of the seven major controllable risk factors for cardiovascular disease (4). Coordinators should promote CCM patient compliance with cholesterol screenings and maintenance to reduce risks of developing cardiovascular conditions. Coordinators should be proactive through regular monitoring of cognitive status and also confirming daily assessment of skin checks for CCM patients as well. Additionally, CCM patients living with diabetes should be urged to have routine podiatry and eye care visits, due to nerve and blood vessel damage from diabetes.  Through these prevention efforts, amputation of toes, feet, or legs can be prevented, as well as vision conditions such as cataracts, glaucoma, or blindness.

Locate Resources for Diabetic Patients

Patients with diagnosed diabetes incur average medical expenditures of about $13,700 per year, of which about $7,900 is attributed to diabetes (3). Hospital inpatient care holds 43% of total medical costs, while diabetes prescription medications reflect 18% of patient’s medical expenditures. CCM coordinators should reduce patients’ emergency room visits, as well as recognize elevated healthcare costs and intervene. Online discounts, pharmacy comparisons, and benefit programs are a few ways a CCM coordinator may relieve financial strains for patients with diabetes.

Below are potential items a diabetic patient may require CCM coordinator assistance obtaining:

  • Glucometers
  • Compression stockings
  • Diabetic medications
  • Prescription glasses
  • Therapeutic shoes/inserts
  • Orders for in-home assistance
  • Canes, walkers, wheelchair, etc.


Resources such as assistance programs, local community organizations and support groups should be made available for CCM patients, caregivers, and their families to relieve stressors of financial difficulty  and help cope with diabetes and its’ complications. Chronic Care Management can provide much needed support to diabetics and improve self-management of this expensive and challenging condition.

  1. US National Library of Medicine, National Institutes of Health. US National Library of Medicine, National Institutes of Health. [Online] April 2006. [Cited: November 28, 2016.]
  2. CDC, Centers for Disease Control and Prevention. Centers for Disease Control and Prevention. [Online] June 17, 2014. [Cited: November 28, 2016.]
  3. American Diabetes Association. American Diabetes Association. [Online] 1995-2016. [Cited: November 28, 2016.]
  4. American Heart Association. American Heart Association. [Online] August 2015. [Cited: November 28, 2016.]

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