Medicare patients who participate in the Center for Medicare and Medicaid Innovation's chronic care management program are more likely to stay out of the hospital – and have lower growth in their Medicare costs — because they have connected with community-based resources, according to CMMI's report, "Evaluation of the Diffusion and Impact of the Chronic Care Management Services."

The Centers for Medicare and Medicaid Services launched the chronic care management program in 2015 to help provide support for patients with multiple chronic conditions between the times they visit their health care provider. The program comes with a new Medicare-benefit that provides "in-between visit" revenue to participating providers – intended to enhance their focus on goal-directed, person-centered care planning, and to provide "aging-in-place" resources such as proactive care management.

The study showed that patients in the CCM program had lower hospital, emergency department and skilled nursing facility costs compared than the comparison group, resulting in a lower growth in total costs to Medicare.