Chronic Care Management

Chronic Care Management (CCM) is defined as the non-face-to-face services provided to Medicare beneficiaries who have multiple (two or more), significant chronic conditions. In addition to office visits and other face-toface encounters (billed separately), these services include communication with the patient and other treating health professionals for care coordination (both electronically and by phone), medication management, and being accessible 24 hours a day to patients and any care providers (physicians or other clinical staff). The creation and revision of electronic care plans is also a key component of CCM.

Healthcare Spending

$3 out of every $4 ($7900) spent on healthcare is spent for every American with a chronic disease.

Chronic Conditions

2 out of every 3 Medicare Beneficiaries have 2 or more chronic conditions.


Healthcare costs are 5 times higher for patients with 2 or more chronic care diseases.


29 Million people in the US have Diabetes.

86 Million people in the US estimated as pre-diabetic.


(High Blood Pressure)

75 million American adults (29%) (1 of every 3) have High Blood Pressure.

Congestive Heart Failure

45 million people have been diagnosed with Congestive Heart Failure (CHF)



Engage patients to achieve better outcomes

Increase practice revenue

Access new Chronic Care Management  Codes



Personalized healthcare and plan

Access to personal health data

Daily monitoring and risk stratification by health advocates