Helping practices provide in-between visit chronic care management.

Improve the health of your chronically ill patients and the financial health of your practice. Now you can provide more efficient, in-between visit care to chronically ill patients while collecting extra revenue for this vital work. Chronic Care Management is a leading provider of CCM technology and services to patients and practices throughout the United States.

Why work with Chronic Care Management?

The Chronic Care Management solution focuses on “in-between visit” care. Care between doctor visits has not been a focus of our healthcare system—until now. It is now known that focusing on what happens to people in-between their healthcare appointments is one of the most important aspects of the care of people with chronic conditions.

In order to provide appropriate in-between visit care, strong collaboration is needed between physician, staff, patient, caregiver. Providing in-between visit care can be a disruption to a practice’s workflow. Designing and updating care plans, focusing on care transitions, ensuring medication reconciliations are completed, ensuring regular primary care follow up–these activities are time consuming and require dedicated staff time and focus.

When you decide that you need a partner to deliver optimal in-between visit care to your patients–whether you are thinking about CCM, CPO, CPC+, MSSP, ACO, BPCI–we can help. We are collaborative partners to practices and organizations throughout their care management journey. It’s what we love to do.

CCM Program Features

  • Cloud-based, portable person-centered care plans for Medicare, Medicaid and Commercial beneficiaries
  • Robust Risk Stratification capability, enabling care management work flow from high to low risk
  • Capture of non-visit revenue via chronic care management codes (CPT 99490, CPT 99487 and CPT 99489) in addition to care plan oversight support (CPT G0181/82) with 3rd-party tested, robust audit trail and time tracking features
  • Care management support for multiple Quality Measures including MIPS, ACO/MSSP, Bundled Payments for Quality
    Improvement (BPCI), and Independence at Home
  • Support of the Comprehensive Primary Care Plus (CPC+) program and its risk stratification and quality measures
  • Full service care management clinical staff solutions that provide supervised, quality care management staff services to patients in collaboration with the patient’s practitioner(s)
  • Single Sign On technology enabling efficient technology usage
  • Advanced scheduling / Call Center support technology to address the continuity of care and community outreach to the patients in-between physician visits
  • Full CCM support for Federally Qualified Health Centers