Comprehensive, coordinated care for patients who need ongoing attention.
Patients with multiple chronic conditions require more than occasional office visits. They need consistent communication, personalized care planning, and coordinated support.
What our CCM program does.
Best for: patients with two or more qualifying chronic conditions.
- Coordinate ongoing care for patients with two or more qualifying chronic conditions.
- Develop and maintain individualized comprehensive care plans.
- Support medication management and treatment adherence.
- Facilitate communication between primary care providers, specialists, and patients.
- Provide structured patient outreach, education, and follow-up.
- Identify gaps in care and support timely clinical escalation.
A month of care, coordinated and documented.
For a patient with diabetes, hypertension, and heart failure, a month of chronic care management is a series of small, connected tasks. Each one keeps care from falling through the gaps between providers.
Our physician-led approach organizes that work around the patient’s overall clinical needs and the treating physician’s objectives, not just around reaching a monthly threshold.
- Care plan reviewed and updatedOpen
- Medication reconciliationOpen
- Cardiology follow-up coordinatedOpen
- Lab results shared with primary careOpen
- Patient education callOpen
- Interactions and time documentedOpen
How we run CCM with your practice.
Implementation, outreach, documentation, and billing support are part of the program, so it fits around your existing team.
- Identify
Identify qualifying patients
We help identify patients with two or more qualifying chronic conditions, then manage education, consent, and enrollment.
- Plan
Build an individualized care plan
Each patient receives a comprehensive care plan built around the treating physician’s objectives, and kept current as their needs change.
- Engage
Structured outreach and coordination
Regular outreach, medication support, education, and communication with specialists keep care connected between visits.
- Escalate
Close gaps, escalate when needed
Gaps in care are identified and escalated to the right clinician in time. Every interaction is documented and time is tracked for billing support.
Our physician-led philosophy ensures that chronic care management is designed around the patient’s overall clinical needs and the treating physician’s care objectives, not just monthly operational targets.
All services are subject to applicable patient eligibility, payer coverage, physician involvement, consent, documentation, staffing, medical necessity, and Medicare billing requirements. Reimbursement depends on applicable coding and coverage criteria.
Related programs
Considering CCM for your practice?
Schedule a complimentary practice assessment. We will look at your patient population and tell you honestly whether this program fits.