Chronic Care Management

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Chronic Care Management is a Medicare-supported program designed for patients with two or more chronic conditions such as diabetes, heart disease, COPD, or hypertension.  Our Chronic Care Management (CCM) program offers personalized, between-visit support to help patients stay healthier, reduce hospitalizations, and improve overall quality of life.

We provide all the infrastructure, staffing, and technology to deliver high-quality Chronic Care Management without adding burden to your clinical team. Our care coordinators work as an extension of your practice to ensure patients get the support they need, between visits.

• Regular monthly check-ins from our care team
• Personalized care plans and health coaching
• 24/7 access to health information
• Medication management and appointment scheduling support
• Reduced emergency room visits and hospitalizations

• Improved patient outcomes and satisfaction
• Increased Medicare reimbursements through CPT code 99490 and related codes
• Streamlined chronic care workflows
• Enhanced patient engagement and loyalty

• 23% reduction in hospitalizations for CCM participants (CMS, 2022)
• $74 monthly reimbursement per patient for CPT 99490
• 80% of U.S. adults over 65 live with multiple chronic conditions (CDC)
• 70% of patients in CCM programs report improved self-management (AMA)

Patients with two or more chronic conditions that are expected to last at least 12 months and place them at significant risk of health decline or hospitalization. Common conditions include:

• Diabetes
• Heart failure
• COPD or asthma
• Hypertension
• Arthritis
• Depression or anxiety