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Chronic Care Management Program: How-to Guide 

A Chronic Care Management (CCM) program provides a more efficient way to care for patients with two or more chronic conditions; and when done right, it results in four important benefits:  

  1. Enhanced patient experience 

  2. Reduced costs 

  3. Improved healthcare outcomes 

  4. Improved clinician experience 

 In this eBrief, Samuel L Church, MD, MPH, CPC-I, CPC, CRC, FAAFP, breaks down how to create an integrated and comprehensive CCM program that results in a high performing, patient-centered medical home. 

Presented By

Dr. Church

Samuel L Church


Samuel Church, MD, MPH, CPC, CRC, CPC-I, is a solo private practice rural family physician, providing both inpatient and outpatient services. His practice is a recognized NCQA Patient Centered Medical Home. Dr. Church teaches medical students for the Medical College of Georgia and is on the faculty for Northeast Georgia Medical Center Family Medicine residency program, where he is responsible for the coding and practice management curriculum and is a coding instructor for the local community college. In addition to speaking and teaching on various coding topics at regional and national conferences, Dr. Church consults for both small practices and health systems on HCC coding, practice workflow, and chronic care management implementation and coding. Dr. Church serves as advisor to the AMA CPT® Editorial Panel for the AAFP and also serves on numerous quality and compliance advisory groups.

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