Empowering Better Health with Chronic Care Management Software
Proactive, personalized care for patients with multiple chronic conditions—delivered through advanced chronic care management software
Transform Chronic Disease Care with Advaa Health
Advaa Health equips practices with a comprehensive chronic care management solution that supports structured, ongoing care. Through our powerful CCM software, physicians can streamline operations, enhance patient engagement, and unlock a consistent revenue stream.
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 program is designed to support value-based care while enhancing practice efficiency.
Full Scope of CCM Services
Fully aligned with CMS 2025 guidelines and ideal for deployment via modern chronic care management apps or platforms
- 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 Partner with Advaa Health?
Boost your practice with Advaa’s all-in-one chronic care management solution—designed for fast implementation, low overhead, and high ROI. Whether you’re new to chronic care management services or expanding your program, 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 software is a CCM platform that helps physicians track care plans, manage chronic conditions, and simplify CMS billing.
Patients with two or more chronic conditions expected to last 12+ months and at risk of health decline qualify for chronic care management services under Medicare.
CCM program improves medication adherence, care coordination, and overall health outcomes. Advaa Health CCM app keeps patients connected between visits.
Physicians can gain predictable CMS reimbursement, improve patient engagement, and reduce administrative burden. Advaa Health CCM software streamlines billing and care plans.
CCM programs are delivered through monthly remote check-ins, care coordination, and 24/7 provider access. Advaa Health CCM solution supports secure delivery via phone, portals, and digital tools.
