Evaluation of a Chronic Care Management Model for Improving Efficiency and Fiscal Sustainability

Chronic care management is effective. Barriers to program durability include dependence on the provider–nurse duo to carry out labor-intensive services and the lack of a fiscally sustainable model. Between January and October 2022, an expanded chronic care management team—consisting of a provider, nurse, community health worker, and pharmacist—conducted a four-month intervention in an ambulatory setting. This intervention, using a convenience sample of 134 Medicare patients with uncontrolled type 2 diabetes or hypertension, demonstrated statistically significant improvements in controlling type 2 diabetes (P < .01) and blood pressure (P < .001). Direct provider workload decreased, and the Medicare reimbursement rate was 85.5%.