Federally Qualified Health Centers (FQHCs) are critical to the delivery of comprehensive healthcare services to underserved populations. When it comes to chronic disease management, the stakes are even higher. Chronic conditions like diabetes, hypertension and heart disease require long-term care that prioritizes patient engagement, operational efficiency and provider education. The Centers for Medicare and Medicaid Services (CMS) first introduced a proactive program to address disease management in 2015 – Chronic Care Management (CCM). In 2018, CMS created the G0511 code so that FQHCs could also furnish CCM services. Now, in 2025, FQHCs are able to bill the individual CPT codes associated with CCM as other fee-for-service organizations do.
With these new opportunities to address the unique needs of the patient populations they serve, FQHCs should consider a few key strategies for establishing and sustaining a successful CCM program.
Start with Patient Identification and Stratification
CMS guidelines require that patients enrolled in a CCM program have two or more chronic conditions that are expected to last for at least twelve months and place them at an increased risk of death or acute exacerbation.
Accurate patient identification and stratification form the foundation of an effective CCM program. By understanding which patients need the most care, provider teams can allocate resources to make the greatest impact. To get started, conduct thorough patient evaluations to identify individuals with chronic conditions such as COPD, asthma, diabetes, and cardiovascular disease. Consider additional risk factors like age, comorbidities and social determinants of health.
Electronic health records (EHR) and data analytics tools can be used to stratify patients based on their diagnoses, risk levels and care needs.
Patient Engagement and Education Boost Outcomes
A truly effective CCM program doesn’t just treat conditions — it puts patients in control of their health. Patient engagement, which is key to fostering better health outcomes and encouraging self-management, starts with the creation of individualized care plans. These should include clear goals and treatment strategies that align with each patient’s health concerns, lifestyle, and preferences, and per CMS guidelines, should be documented electronically.
Plans should also provide the supplementary tools that patients need to succeed. FQHCs can offer workshops, easily accessible written materials, and videos on topics such as medication adherence, nutritional and exercise guidance, monitoring symptoms and warning signs, and the usage of digital communication tools.
Actively engaging patients with technology like mobile apps, patient portals, and telehealth platforms offers continuous support, provides reminders for appointments or medication, and facilitates quick communication between patients and providers.
Manage Resources to Help Alleviate Staffing Challenges
CCM programs can be resource-intensive, requiring ongoing staff engagement and administrative oversight. However, FQHCs can improve efficiency and financial sustainability by leveraging third-party clinical teams to supplement their workforce. Since CCM services can be billed under the general supervision of the billing provider, external care partners — such as remote nursing teams or telehealth providers — can deliver services without straining organizational personnel.
In addition to optimizing staffing, securing funding from government grants, private foundations, and partnerships can further support program longevity.
Continuous staff training is essential to maintaining high-quality care, so apprise teams of best practices in managing chronic conditions, the use of technology tools, and cultural competency. Investing in ongoing professional development to keep teams informed may also boost employee motivation and morale. Regular program performance assessments can identify areas for additional training and growth, as flexible programs that evolve with data insights are more likely to succeed in the long run.
Tailor Community Outreach and Engagement
Many patients served by FQHCs face significant barriers to accessing care, including geographical challenges, financial hardships, and coverage limitations. Proactive community outreach can bridge those gaps and enhance understanding. FQHCs that collaborate with local nonprofits, faith-based groups, and public health initiatives are well-positioned to advance chronic disease prevention and connect with underserved populations.
Tailoring program outreach – and medical interventions – to the cultural, linguistic, and socioeconomic nuances of the local patient demographic is important. Staffing limitations can create barriers to delivering personalized care. Leveraging external care partners, such as community health organizations, telehealth providers, and social services, extends the reach of CCM programs without overburdening in-house teams. Partnerships help bridge gaps in language access and cultural competency, ensuring more patients receive the support they need. Prioritizing bilingual resources and localized outreach strategies can significantly improve a program’s impact.
Impactful CCM Programs Empower FQHC and Patients to Achieve Better Health Together
Implementing a well-designed, sustainable CCM program can amplify the impact made by FQHCs as they administer transformative care to those who need it most. It’s truly an opportunity to enhance the health and well-being of vulnerable populations and contribute to life-changing outcomes.
To explore more solutions for optimizing chronic care management, reach out to our team for customized insights and options!