Chronic Care Management
Structured, proactive support between office visits for patients managing multiple chronic conditions.
What is CCM?
Chronic Care Management (CCM) provides eligible Medicare beneficiaries and other covered patients with continuous, non-face-to-face care coordination.
Our clinical staff acts as an extension of the primary care physician, reaching out to patients monthly to review medications, assess symptoms, and ensure care plans are being followed.
Commonly Managed Conditions
- Diabetes
- Hypertension
- Heart Disease
- COPD
- Chronic Kidney Disease
- Arthritis
The Monthly Workflow
Personalized Care Plan
Creation of a comprehensive care document tracking all health issues, medications, and providers.
Patient Outreach
Minimum of 20 minutes of clinical staff time directed by a physician, engaging the patient by phone.
Provider Communication
Detailed notes and status updates sent back to the primary care provider's EHR.
Implement CCM at Your Practice
Avid Care provides the clinical staff and technology platform to manage the CCM program under your direction, improving patient outcomes while meeting documentation requirements.
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