Form CMS-10209 CCIP_Reporting_Tool

Chronic Care Improvement Program (CCIP) Reporting Tool
Chronic Care Improvement Program (CCIP): A program to manage chronic conditions
by preventing and or minimizing the effects of the condition through patient selfmanagement and integrated care in order to improve health outcomes and decrease
costs.

Medicare Advantage Organization (MAO) Information
MAO Name
Contract #

Identification #

MAO Location

Contact Person

Name

Title

Telephone

MAO Plan Type:

HMO

PPO

Email
PFFS

SNP:
Other ________
___ Chronic
(type) ______________
___ Dual Eligible
___ Institutional

CCIP Initial Plan Approval Submission:
___ Yes

State the length of time intended for the program: ________________

___

Subsequent Year Report #:

No

1__ 2__ 3__ 4__ 5__

CCIP Title:_________________________________________________________________
Provide a brief summary of the CCIP to include the specific clinical foci and expected
outcomes.

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays
a valid OMB control number. The valid OMB control number for this information collection is 0938-1023. The time required to complete
this information is estimated to average 5 hours per response. If you have comments concerning the accuracy of the time estimate or
suggestions for improving this form, please write to: CMS 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore,
Maryland 21244-1580.

CCIP Reporting Tool

PLAN
A. Basis for selection
Describe the basis for selecting the specific chronic condition for the CCIP with
anticipated or desired measurable outcomes.
A1.
Disease
State

A2. Rationale for
Selection

A3. Relevance to the
Plan Population

A4. Anticipated
Outcomes

ICD-9 code(s)

A5. Data Source(s) for Selected Chronic Condition (check all that apply):
__MAO Part C Reporting Requirements

__Medical Records
__Claims (Medical, Pharmacy, Laboratory)

__Encounter Data
__Audit Findings

__Appointment Data
__Plan Data (complaints, appeals, customer service)
__Health Risk Assessment (HRA) Tools
__Surveys (enrollee, beneficiary satisfaction,
other)
__Minimum Data Set (MDS) – Institutional SNP

__Health Effectiveness Data Information Set (HEDIS®)
__Health Outcomes Survey (HOS)
__Consumer Assessment of Healthcare Providers and
Systems (CAHPS®)
__ Registries (e.g., cancer, COPD)
__Other Sources _______________________

B. Program Design
B1. Population Identification Process:
B1a. Describe the Target Population
B1b. Method of identifying members: (drop down box)
___ Health risk assessment
___ Claims Data (Medical, Pharmacy, Laboratory)
___ Encounter Data
___ Enrollment Data
___ Utilization Management Data
___ Case Management Referrals
___ Surveys
___ Registry
___ Other __________________________

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B1c. Risk Stratification: (patient acuity level)
B1d. Enrollment Method:

____Opt in

___High

___Medium

___Low

____Opt out

Opt in – Member must ask for inclusion in program.
Opt out – Member automatically included in program and must ask to be excluded

B2. Evidence Based Medicine: (Provide current clinical practice guidelines and evidence-based
treatment modalities, standards of care, evidence-based best practices, etc.)

B3. Care Coordination Approach: (Describe the model, e.g., integration, collaboration,
community resources, and communication among team members including provider, patient, and
CCIP team members.)

B4. Education: (Describe the method of education and the topics covered e.g., diabetes,
COPD.)

B4a. Patient Self Management
Method

Topics Covered

N/A

Training
Support
Monitoring
Follow-up
Other

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B4b. Provider Education
Method

Topics Covered

N/A

Training
Support
Monitoring
Follow-up
Other
B5. Outcome Measures and Interventions:
B5a. Goal:

B5b. Benchmark:

B5c. Goal: __ Clinical

__ Utilization

__ Satisfaction Survey
Benchmark: __ Baseline

__ Access

__ Quality of Life (QOL)

__ Other ________________________________________

__ Internal

__ External

B5d. Intervention:

B5e. Rationale for specific intervention related to goal or benchmark:
B5f. Measurement Methodology:

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B5g. Timeline:

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B6. Communication Sources including the Interdisciplinary Care Team and
Patients: (Describe how the program integrates continuous feedback among all parties.)
B6a. Sources (Check all that apply.)
__ Electronic Communications (Website, portal, email, etc.)
__ Telecommunications (Phone calls, phone text messages, public media, etc.)
__ Written Materials (Brochures, provider newsletters, member newsletters, flyers, etc.)
__ Surveys (Satisfaction Survey, Comment Cards, Complaint Tracking, etc.)
__ Face-to-face Patient Education
__ Other ____________

B6b. Target Audience (Check all that apply.)
__ Providers

__ Care Team

__ Patients

__ Educator

__ Family Members

__ Other _________

__ Case Manager

C. MAO CCIP Responsibility: (Medical Director)
Name of Individual

Title

E-mail Address

Phone

Date of
Approval

D. CMS Regional Office Approval:
__ Yes
__ No

Reason: ____________________________________________________
_____________________________________________________

Name of Individual

Title

Date of Approval

The above information will remain in the system for reporting in subsequent years.

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DO
E. Program Implementation, Review and Revision (Provide the results or
findings from each intervention, any barriers encountered, risk mitigation for the barriers identified
and the anticipated impact on the goal or benchmark.)
Auto Populate from Demographics Section

Cycle Period: __ Year 1

__ Year 2

__ Year 3

__ Year 4

E1. Education: (Describe the actual method of education and the topics that were covered e.g.,
diabetes, COPD.)

E1a. Patient Self Management
Method

Topics Covered

N/A

Topics Covered

N/A

Training
Support
Monitoring
Follow-up
Other
E1b. Provider Education
Method
Training
Support
Monitoring
Follow-up
Other
E2. Intervention: Describe the actions taken or intervention implemented to achieve the goal.
Auto Populate from Plan Section

E3. Results or Findings: Provide an analysis of the initial results or findings.

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E4. Barriers Encountered: Describe the barriers encountered. (e.g., modification to
intervention, strata targeted, measurement method, clinical, financial, resources utilized)

E5. Mitigation Plan for Risk Assessment: Describe the actions taken to mitigate the
barrier(s).

E6. Anticipated Impact on the Goal and/or Benchmark: Describe the impact you expect
the risk mitigation to have on the goal and/or benchmark.

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STUDY
F. Results: Complete the table below for each applicable measurement period.
F1. Goal: (Auto populate from Section B5.)

F2. Benchmark: (Auto populate from Section B5.)
F3.
Timeline

F4.
Dates of
Implementation

F5.
Sample
Size or
Percent of
Total
Population

F6.
Numerator
(skip if not
applicable)

F7.
Denominator
(skip if not
applicable)

F8.
Total
Percent
or Result

F9.
Other
Data or
Results

F10.
Analysis
of
Results
or
Findings

Initial Period

Remeasurement
Period #1
Remeasurement
Period #2
Remeasurement
Period #3
Remeasurement
Period #4

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ACT
G. Next Steps: Identify the next steps based on the evaluation of the CCIP for this
cycle, whether the goals were met or not met. (Check all that apply.)
Action Plan (drop down box):
G1. __ Continue the program with no change(s).
G2. __ Continue the program with change(s).
Describe the planned change(s):
G3. __ Develop a Quality Improvement Project (QIP) to study one or more
aspects of the program.
Describe the QIP:
G4. __ Discontinue the program.
Reason for discontinuation:
G5. __ Re-evaluate and change the goal or benchmark selected.
New Goal or Benchmark:
G6. __ Expand the program.
Expansion plans:

Expected outcome:

Proposed timeline:

G7. __ Identify additional Interventions.
New intervention:

Expected Outcome:

Proposed timeline:

G8. __ Re-evaluate data and criteria.
Describe changes to data and criteria:
G9. __ Other
Describe:

Your report is complete. Thank you for submitting your CCIP.

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SUBMIT

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