Case Study: Naples Internal Medical Associates cuts hospitalizations 20–25% and bills Medicare for ~400 CCM patients with eClinicalWorks

Implementing Chronic Care Management to Improve Patient Outcomes

Naples Internal Medicine Associates, a small primary‑care practice in Naples, Florida, serves a predominantly older population with high rates of multi‑morbid chronic conditions. Their challenge was to implement the new CMS Chronic Care Management (CCM) rule (effective Jan 1, 2015) — enrolling eligible Medicare patients and reliably documenting 20+ minutes/month of non‑face‑to‑face care so the practice could capture the $42/month reimbursement while improving outcomes.

Working with eClinicalWorks, Naples used EHR dashboards, automated billing, care‑plan tools, time‑tracking and a tiered staffing model to identify, enroll and manage roughly 350–400 CCM patients. The program enabled consistent billing to Medicare, recorded required monthly care time, produced a 20–25% reduction in hospitalizations, achieved 90–95% patient satisfaction, and saw about half of participants engage via the patient portal.