How to Increase Patient Enrollment in Your CCM Program (Without Burning Out Your Staff)
Quick Answer: How do you increase enrollment in a Chronic Care Management program?
The practices that consistently grow Chronic Care Management (CCM) enrollment do three things well:
- They use data from the EHR to proactively identify eligible patients with two or more chronic conditions, instead of waiting for the next office visit.
- They clearly explain the benefit to the patient — ongoing support between visits, help with medications, fewer urgent care trips — and address cost up front.
- They make enrollment easy by having one trained person own outreach, education, consent, and onboarding instead of passing the patient between multiple staff members.
Now let’s go deeper.
Step 1: Know Exactly Which Patients Qualify — and Which Ones You Should Call First
Your CCM program won’t grow if you only mention it during an Annual Wellness Visit and hope the patient says yes.
Build a list
Under Medicare rules, a patient qualifies for CCM if they have two or more chronic conditions expected to last at least 12 months (or lead to significant risk without ongoing management).
Common examples: hypertension, diabetes, COPD, CHF, arthritis, depression.
Action items
- Run a monthly report in your EHR of all patients 65+ with ≥2 active chronic diagnoses.
- Flag high-risk groups:
- Patients with recent ER or hospital visits.
- Patients with medication adherence issues.
- Patients who call the nurse line frequently.
- Recently discharged patients at high readmission risk.
Why this matters
These are the patients most likely to say “Yes, I’d like more help staying on top of everything between visits.” Studies of Medicare beneficiaries in CCM programs have shown fewer emergency department visits, fewer hospital admissions, and lower total cost of care compared to similar patients not enrolled.
Step 2: Teach Patients What CCM Actually Does for Them (Not How You Bill for It)
Most patients don’t enroll because they don’t understand what they’re being offered.
Use human-centered language
Try phrasing like:
- “You’ll have a dedicated care manager who checks on you between visits and helps you stay on top of medications.”
- “If something changes, you can call us and we’ll coordinate care for you.”
- “This is a service for people with ongoing conditions. After your Part B deductible, Medicare usually covers 80%.”
Educate before you enroll
Don’t pitch enrollment cold. Mention CCM during follow-up calls, refills, discharge follow-up, or pre-visit planning. Multiple calm exposures build trust and clarity.
Step 3: Put the Right Person in Charge of Enrollment Conversations
If “whoever answers the phone” is explaining CCM, you’ll get inconsistent messaging and low enrollment.
Assign ownership
High-performing programs designate one care coordinator or enrollment specialist who:
- Reviews the eligibility list.
- Personally calls each patient.
- Explains CCM in plain language.
- Answers cost questions confidently.
- Documents consent immediately.
What makes an effective enrollment specialist
- Clinical credibility + empathy — speaks like care, not collections.
- Persistence without pushiness — expect 2–3 contact attempts per patient.
- Clarity under pressure — handles objections with confidence and compassion.
Provide this person a script, FAQs, and measure conversion rates as a true KPI.
Step 4: Make Enrollment Frictionless
Even if a patient says “yes,” you can still lose them in the handoff if your workflow is clunky.
Streamline your process
- Patient agrees to participate.
- Specialist documents informed consent immediately.
- Care plan kickoff is scheduled.
- Patient knows exactly what happens next.
Avoid:
- Mailing consent packets.
- “Call us back if you’re interested.”
- Hand-offs to multiple staff.
Automation — templated care plans, EHR-integrated documentation, electronic consent — saves staff time and prevents enrollment drop-off due to administrative burden.
Step 5: Keep Patients Engaged So They Stay Enrolled
Enrollment is the start; retention is the result.
Be proactive, not reactive
Call with purpose: “Your blood pressure readings looked higher this week — let’s talk.” Patients who feel supported are less likely to use the ER or switch practices.
Close the loop
Address medication issues, mobility barriers, or scheduling frustrations. Each solved problem builds loyalty.
Celebrate progress
“Your A1C is down two points since last quarter — great work!” Positive reinforcement strengthens connection.
Maintain continuity
Use the same care manager month to month. Familiarity fosters trust and long-term participation.
Why Patients Say “No” — and How to Handle It
“I already see my doctor. I’m fine.”
“This doesn’t replace your visits — it supports you between them so small issues don’t become emergencies.”
“Are you just trying to bill me?”
“This is a service that helps you manage ongoing conditions. After your deductible, Medicare covers 80%.”
“I don’t want more phone calls.”
“You’ll get one scheduled call each month from the same care manager — no spam, just support.”
“I don’t want to share my information.”
“All information stays within your medical record here. Nothing is sold or shared externally.”
Document common objections and train staff to address them confidently. Transparency builds trust.
Putting It All Together
To grow CCM enrollment sustainably:
- Identify eligible, high-need patients using your data.
- Train one dedicated person to manage outreach and consent.
- Communicate benefits clearly and discuss cost upfront.
- Capture consent immediately.
- Deliver measurable value in the first 60 days to improve retention.
CCM done right is preventive care, care coordination, and practice differentiation — not paperwork. It improves outcomes, reduces hospital use, and strengthens patient loyalty.
Need Help Building or Scaling Your CCM Program?
Partner with Bluefish Medical to launch or optimize your Chronic Care Management program.
We help practices:
- Identify and prioritize eligible patients.
- Train or provide expert care coordinators.
- Automate documentation, billing, and consent workflows.
- Deliver ongoing care management that patients value — and Medicare reimburses.