Turnkey CCM & RPM Programs

for Better Patient Care

and New Revenue

We help practices and health systems implement and manage

Medicare-compliant care coordination programs.

Chronic Care Management (CCM)

Home / Chronic Care Management

What is CCM?

Chronic Care Management (CCM) is a patient-centered program created by CMS to support individuals living with two or more chronic conditions. It bridges the gap between office visits, ensuring patients receive consistent follow-up, education, and coordination of care all designed to help them stay healthier, avoid hospitalizations, and improve their quality of life.

Through structured monthly outreach and documentation, CCM enables care teams to proactively manage patients’ needs while generating recurring reimbursement for the time they already dedicate to patient support.

How CCM Works

Identify & Enroll Eligible Patients – Patients with multiple chronic conditions are identified and enrolled in the program with their consent.
Comprehensive Care Plan – A personalized care plan is developed that outlines goals, interventions, medications, and self-management strategies.
Monthly Care Coordination – Clinical staff maintain regular communication with patients to address needs, adjust care plans, and reinforce treatment adherence.
Documentation & Time Tracking – All activities are logged and tracked to meet CMS’s 20-minute monthly time requirement for billing.
Billing & Compliance – Practices bill for the time spent providing non-face-to-face care management services in compliance with CMS guidelines.

Benefits for Patients

Continuous Support: Regular contact helps patients feel cared for and connected between appointments.
Improved Health Outcomes: Early intervention and consistent follow-up reduce complications and hospitalizations.
Simplified Care Coordination: Providers, specialists, and pharmacists stay aligned on the same care plan.
Education & Empowerment: Patients receive education to better manage their conditions and maintain independence.

Benefits for Practices

Predictable, Recurring Revenue: CCM reimburses for the time staff already spend managing chronic patients.
Enhanced Patient Retention: Ongoing engagement builds stronger, longer-term relationships with patients.
Reduced Provider Workload: Delegating care coordination to trained clinical staff frees up provider time.
Improved Quality Metrics: Better outcomes contribute to stronger performance in value-based care programs.
Compliant & Scalable: Structured processes ensure regulatory compliance and program growth across multiple providers or sites.

Our Role

CCMRPM Help, we specialize in helping practices and healthcare organizations design and implement CCM programs that work. From defining workflows and creating compliant care plans to training staff and optimizing documentation, we handle the details so your team can focus on what matters most—delivering care that improves lives and builds sustainable revenue.