Streamline Your Practice with Chronic Care Management Software
Deliver proactive CCM service for patients with multiple chronic conditions while reducing admin work and improving care coordination.
Improve Patient Outcomes & Practice Efficiency with Our CCM Program
Advaa Health structured, ongoing chronic care management program enhances patient outcomes, simplifies workflows, and creates a steady, recurring revenue stream for your practice — with certified care coordinators handling most of the clinical follow-ups.
What is Chronic Care Management?
Chronic Care Management (CCM) is a Medicare-supported service that provides continuous, coordinated care for patients living with two or more chronic conditions—like diabetes, hypertension, or heart disease. It involves regular follow-ups, care planning, medication management and communication between healthcare providers and patient trough tech-enabled care using chronic care management platforms.
Our chronic care management software is designed to support value-based care while enhancing practice efficiency.
Full Scope of Chronic Care Management Services
CMS-compliant and designed for seamless integration with modern chronic care management platforms, enabling fast implementation, audit-ready documentation, and improved care coordination — saving your team hours per week.
- Dynamic EHR-based plans covering, Problem lists & prognosis, Medication reconciliation, Psychosocial needs assessment, Measurable treatment goals
- Updated quarterly or with health changes
24/7 Care Coordination
- Transition management (hospital to home)
- Specialist communication
- Medication management & prior authorization support
- Community resource linking (transportation, meal services)
- Monthly 20+ minute clinical check-ins
- Customized self-management education
- Emergency care plan development
- Remote vital monitoring integration (BP, glucose, weight, pulse oximetry)
Compliance Infrastructure
- Automated consent documentation
- Audit-ready time logs
- Secure patient portal (HIPAA-compliant messaging)
Eligibility & Enrollment
Qualifying Patients
- Medicare Part B beneficiaries
- 2+ chronic conditions (e.g., diabetes, CHF, COPD)
- At significant risk of: Acute exacerbation, Functional decline, Hospitalization
Practice Requirements
- Provider-led care team
- EHR with care plan functionality
- 24/7 patient access (direct or contracted)
Key Financial Benefits
-
Monthly billing for
continuous care -
No patient opt-out risk:
92% retention rate -
Zero upfront costs with
Advaa’s turnkey platform
- Monthly billing for continuous care
- No patient opt-out risk: 92% retention rate
- Zero upfront costs with Advaa’s turnkey platform
Why Choose Advaa Health’s Chronic Care Management Solution?
Implement CCM quickly, reduce administrative burden, and maximize practice ROI with our fully managed chronic care management solution — including certified care coordinators, automated eligibility screening, and real-time reimbursement tracking.
Advaa offers:
- End-to-End CCM Solution
- Certified care coordinators
- Automated eligibility screening
- Real-time reimbursement dashboard
- Consent management system
Performance Metrics
30-40%
Reduction in provider administrative burden
28 Days
average ROI for practices
>95%
Clean claims rate
Implementation
Frequently Asked Questions
Chronic Care Management is a medicare program that helps physicians provide coordinated care for patients with two or more chronic conditions, improving outcomes and supporting Medicare billing compliance.
Medicare patients with two or more chronic conditions expected to last 12 months or longer, and who are at risk of health decline or hospitalization, are eligible for CCM services.
CCM helps patients manage chronic conditions more effectively, improves medication adherence, enhances care coordination, and ensures continuous monitoring between office visits.
CCM provides physicians with predictable medicare reimbursement, reduces administrative burden, and improves patient engagement through structured care and coordinated follow-ups.
CCM services are delivered via monthly check-ins, care coordination, and secure communication through phone calls or patient portals.
