Why Patients Drop Out of Your CCM Program — And How to Fix It

Fix My Program Series

Introduction: The Retention Problem

Many practices launch Chronic Care Management (CCM) programs with good intentions and solid operational plans, only to find themselves asking a painful question a few months in: “Why aren’t our patients sticking with the program?” If this sounds familiar, you’re not alone. It’s one of the most common challenges faced by practices operating care management programs. In fact, it’s the leading reason many physicians discontinue these initiatives—dropout rates range from 27% to 29% for Chronic Care Management (CCM) and a staggering 45% to 49% for Remote Patient Monitoring (RPM) programs¹. So, what’s going wrong?

The encouraging news is that this isn’t a participation problem. Patients do care about their health, and the engagement puzzle has already been solved in practices just like yours. What you’re facing is a value problem—and that signals an opportunity to recalibrate your program for long-term success. Like any rational consumer, patients are reluctant to pay for or be inconvenienced by services they don’t find meaningful. Whether it’s the cost of copays or the disruption of frequent phone calls, they’ll disengage if the value isn’t clear and tangible.

This whitepaper dives into the reasons behind this disconnect—and outlines actionable strategies your program can use to fix it.

Section 1: Valid Reasons Patients Leave — and the Ones You Can Change

Let’s start with the obvious: there are legitimate reasons patients discontinue CCM services.

Health status changes
Transitions to hospice or assisted living
Behavioral health episodes
Hospitalizations or temporary events (like extended travel)

But these are the exceptions. When drop-off rates are high, the more likely explanation is that patients don’t perceive enough value to justify their time or co-pay.

Section 2: The Visibility Gap

Behind the scenes, your team may be doing a tremendous amount of work for chronic and fragile patients: coordinating care with other physicians, titrating meds, ensuring preventative services are scheduled or performed, talking to family members, med recs, associated preventative services and screenings, reviewing discharge summaries – it’s endless.
But if patients don’t see this work, there’s no way they can know it’s happening and that its being done specifically for them. Even today, most of this work is done behind the scenes without the patient even knowing it happens.

With the introduction of CMS reimbursements for CCM, that invisible work became billable—but also, in the patient’s eyes, optional. Now that there’s a co-pay attached, patients expect to see and feel value in return. This is a major shift in expectations and an opportunity to help patients understand how much work your both putting into keeping them well.

It is rational human behavior not to spend money on something that appears to deliver no return.

Section 3: Make the Value Visible

Programs that keep patients engaged do one thing exceptionally well: they close the visibility gap.

Using the capabilities of your EHR or CCM solution, you can:

Automate patient-facing monthly updates: “Here’s what we did for you this month…”
Embed important reminders or patient education (e.g., flu shot reminders, fall prevention tips, warning signs)
Share clinical actions taken on the patient’s behalf

For example, if you reviewed the preventative care activities to ensure no care gaps were open, let the patient know. If the medication you titrated was done after a conversation with a specialist or the nurse that the patient engaged with, communicate that also. Visible work is tangible value.

This kind of communication turns behind-the-scenes work into tangible value.

Section 4: Reinforcing Participation Through Recognition

Patients respond to recognition. If you’re using RPM or gathering blood pressure data, acknowledge progress. Congratulate patients who show improvement. Offer encouragement where needed.

That simple act of being “seen” makes a significant difference.

Example: Platforms that consistently reinforce value back to patients have reported 86%+ retention at 12 months.

When patients know someone is paying attention to their data and communicating with them, they are far more likely to remain engaged.

Section 5: The Internal Check-In

Ask yourself and your team:

What value does our care management program deliver?
What does it enable us to do for patients that we couldn’t do otherwise?
How are we showing that value back to the patient?

If you can answer those clearly, you’re on the right track. If not, that’s likely why retention is suffering.

Programs that drift from clinical necessity or become checklist-driven tend to lose both patient trust and staff engagement.

Conclusion: Participation Is Earned

Care management programs were never meant to be passive. They are designed to strengthen patient relationships, provide proactive care, and improve quality of life.

If patients aren’t staying enrolled, it’s because they are not seeing the value or experiencing the benefit.

Make your work visible. Show your value. And remember: care that isn’t perceived doesn’t get credited.

This is one best practice that you can begin to fix your program.