Chronic Care Management (CCM)
Manage Chronic Conditions with Ease — We Handle the Monitoring, Documentation, and Support, So You Can Focus on Treatment.
What is Chronic Care Management (CCM)?
Chronic Care Management (CCM) is a Medicare-supported program designed to enhance care coordination for patients with multiple chronic conditions. It provides ongoing support between office visits, ensuring patients receive proactive, continuous, and personalized care. CCM services include care planning, medication management, coordination between specialists, and 24/7 access to healthcare resources, ultimately improving patient adherence, reducing complications, and preventing unnecessary hospitalizations.
For ophthalmologists, particularly retina specialists, Chronic Care Management (CCM) is an invaluable tool for managing patients with progressive eye diseases such as macular degeneration, diabetic retinopathy, and other vision-threatening conditions. These patients require continuous monitoring and proactive intervention to slow disease progression, preserve vision, and enhance their overall quality of life. CCM extends care beyond in-office visits, ensuring structured, ongoing support that improves patient outcomes, increases treatment adherence, and strengthens long-term engagement.
Helping Your Patients Manage Their Chronic Conditions
Chronic Care Management (CCM) Activities
Care Plan Development & Oversight
Monthly Patient Engagement
Care Coordination
Appointment & Screening Reminders
Documentation & Billing Support
Care managers (registered nurses or certified medical assistants) collaborate with your practice to create and update personalized care plans addressing retinal conditions, comorbidities, medication adherence, and lifestyle changes (e.g., smoking cessation for macular degeneration).
Care Plan Development & Oversight
Conduct at least 20-minute monthly phone or video check-ins to review health status, discuss symptoms (e.g., vision changes), reinforce treatment adherence (e.g., anti-VEGF injections), and answer questions.
Montly Patient Engagement
Coordinate with other providers (e.g., endocrinologists, primary care physicians) to manage comorbidities impacting retinal health, such as uncontrolled diabetes.
Care Coordination
Schedule and remind patients about critical appointments, like intravitreal injections or retinal imaging, to prevent care gaps.
Appointment & Screening Reminders
Document all interactions in your electronic health record (EHR) system, ensuring compliance with Medicare CCM requirements (e.g., CPT codes) and tracking time for reimbursements.
Documenation & Billing Support
CCM Key Program Benefits
Personalized Care Plans
Tailored care strategies for each patient, addressing their unique needs and chronic eye conditions.
Patient Support
Ensures patients have continuous access to healthcare guidance, reducing the need for urgent visits.
Medication and Treatment Adherence
Helps patients stay on track with prescribed treatments, improving compliance and outcomes.
Specialist Coordination
Streamlines communication between primary care providers, ophthalmologists, and other specialists.
Remote Theraputic Monitoring Integration
Optionally integrates with RPM for real-time tracking of visual changes and health status.
Patient Education & Self-Management Support
Empowers patients with resources to manage their condition more effectively.
CMS-Compliant Documenation & Billing Support
Ensures full compliance with Medicare guidelines while optimizing reimbursements.
Low Vision Support & Rehabilitation Coordination
Connects patients with low vision specialists, assistive technology
resources, and state rehabilitation services to enhance independence and daily functioning. Ensures patients receive the necessary tools,
training, and support to adapt to vision loss, improving their overall quality of life.
Enhance Patient Care & Improve Outcomes with Chronic Care Management!
Support your patients with chronic conditions through our Chronic Care Management (CCM) program. Our solution provides continuous, personalized care, improves medication adherence, reduces hospitalizations, and ensures better health outcomes for your patients.
Contact us today to integrate CCM into your practice and enhance patient care while optimizing your clinical workflows.