Treat vulnerable patients holistically with chronic care management.

Apply a multi-dimensional, coordinated, and comprehensive CCM solution for at-risk patients.

How chronic care management delivers better clinical outcomes.

Increase healthcare access through direct, 24-hour patient support.
Reduce unnecessary hospital or emergency room visits and readmissions.
Ensure continuity of care across providers.
Improve medication adherence for multi-chronic disease patients.
Enhance patient engagement and satisfaction.

Boost patient participation and engagement.

Better outcomes follow when patients engage with clinicians and are part of the care plan. The key is consistent monthly touchpoints of at least 20 minutes, which our CCM platform makes easy with built-in communication tools and trackability of engagement time. Those check-ins can include care plans, prescriptions, chart reviews, appointment scheduling, and referral discussions.

These CCM activities integrate into your existing workflows. Our U.S.-based chronic care managers are an extension of your staff, ensuring care continuity. Patients get the encouragement and attention they need with a seamless experience.

Streamline care management in one place.

Using our CCM solution, management of all processes occurs in one platform. With intuitive technology, you have the features to streamline care management with automatic time tracking.

Our solution facilitates all the requirements for chronic care management, starting with acquiring and documenting patient consent. You then submit the care plan in the platform and begin managing it. As a managed service, we provide chronic care managers to connect with patients regularly to address problems, goals, and next steps.

Create a custom CCM solution to align with your specialty and patient population.

Every practice and its patients are unique, so it’s essential to partner with a CCM company that builds a program based on these needs. Our CCM program enables you to develop individual care plans with goals, barriers, symptoms, problems, medications, and allergies.

Optimize CCM outcomes with greater visibility by monitoring adherence and results.

Chronic condition patients typically need more encounters than those in clinic. With accurate and timely insights into their day-to-day life of managing a chronic disease, you can make data-driven decisions about care plans and track progress against goals.

Implement and scale CCM with easy software and managed services.

Growing and administering CCM programs doesn’t require strain on your internal team. With innovative technology and managed services, building and scaling CCM is not a challenge.
As a managed service, CCM includes our U.S.-based, chronic care management as an extension of your staff. They can enroll and educate patients and conduct encounters. The system captures and transmits data and information to your EHR.

Our platform also handles all the administrative work of managing care plans, as CMS requires. Your program will flourish without demanding time that keeps you away from patient care.

Grow CCM revenue and operational efficiency.

CCM reimbursement requires time tracking and applying proper codes. Our software includes revenue functionality to cover these actions. With a connected platform that simplifies claims and billing, you also achieve operational efficiency, as the built-in billing eliminates hours of manual work.

What is chronic care management?

Chronic care management is a type of remote healthcare that involves supporting patients with two or more chronic diseases. It involves clinician-directed comprehensive care management, care coordination, and patient support via non-face-to-face encounters. The aim is to strengthen the coordination of care and improve clinical outcomes.
How does Medicare reimbursement work for CCM?

Reimbursement from Medicare is on a per-patient monthly basis. The reimbursement rate depends on the complexity and time required for care delivery. There are four CPT® Codes associated with CCM: 99490,99439, 99491, and 99437. You can provide and bill for CCM in tandem with RPM or RTM. FQHCs and RHCs can use G0511 to bill for CCM.
What diseases can CCM manage?

CCM can be a valuable strategy to support many chronic conditions. The most common include CHF (congestive heart failure), COPD (chronic obstructive pulmonary disease), diabetes, hypertension, Alzheimer’s/dementia, arthritis, and cancer.
Can third parties perform the clinical staff portion of CCM?

Yes, clinical staff external to a practice can provide monitoring, but it must be under the direct supervision of a QHCP.
Does CCM require a diagnosis?

Yes, to qualify for CCM reimbursement, a patient must receive a diagnosis of two or more chronic diseases lasting 12 months or longer.
What does enrolling patients in CCM entail?
Enrolling patients in CCM includes:
- Creating and maintaining comprehensive care plans.
- Coordinating with other clinicians.
- Managing medication.
- Offering assistance for chronic disease self-management.

What are the steps of creating a CCM program?

Determine which patients fit the criteria.
Enroll patients in a compliant, secure workflow.
Create care plans.
Deliver clinician-directed interactions with patients.
Track time related to care coordination and physician care.
Submit claims to CMS and/or private insurers.

Close care gaps and empower patients with CCM managed services.

Simplify and streamline continuity of care and proactive management of multiple chronic diseases with CCM from Optimize Health. Through our comprehensive remote care platform, you can personalize care management for disease management. When this ecosystem of care becomes a patient’s health environment, they can live a better quality of life. Give this opportunity to your multi-chronic condition patients.

Start and easily scale your CCM program with a proven, trusted partner.

Implement an intuitive CCM platform that allows you to focus on solving patient care needs, and we’ll do the rest.

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