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Chronic Care Management (CCM) icon

Chronic Care Management (CCM) 

Amazing Charts is proud to partner with Cosán, the industry’s leading healthcare organization creating new pathways to modern aging. Cosán delivers a preventative care coordination tool suite for Chronic Care Management (CCM), Behavioral Health Integration (BHI) & Remote Patient Monitoring (RPM).

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care gap

Care Gaps 

The difference between care that ideally uses all best practices to optimize treatment and the actual care patients receive is the care gap. Recognizing that these gaps exist allows you to efficiently identify how your practice can improve to give all your patients high-quality care. 

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Clinical Quality Measures icon

Clinical Quality Measures 

Clinical quality measures (CQMs) and other population health metrics show a change in how payers, such as Medicare and Medicaid, compensate for treatment. Instead of basing payments on patient volume, now they emphasize care quality.

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Chronic Care Management

Outsourcing preventative care programs like Chronic Care Management (CCM), Behavioral Health Integration (BHI), and Remote Patient Monitoring (RPM) provides your practice with a comprehensive set of care services – removing the burdens many providers face today. These CMS validated programs help reduce the cost of care and improve patient engagement, outcomes, and quality measures while increasing your practice revenue.


A chronic care management module ensures that your patients with chronic conditions have the care they need while ensuring that you get compensated for your time. Additionally, you and your patients will enjoy the following benefits when you integrate chronic care management into your practice:

  • Better Outcomes: Better care coordination and increased patient involvement will lead to better health outcomes, and that is something all practices strive to achieve.
  • Reimbursement: Practices receive reimbursement for providing a minimum of 20 minutes of CCM services per patient in a given month.
  • Patient Involvement: Encouraging patients to use CCM services gives them the support and motivation they need to follow good health habits between office visits.
  • Increased Compliance: Using a digital program to gather and provide quality metrics makes it much easier to communicate with third party reimbursement entities such as CMS or insurance companies.
  • Reduced Emergency Care: Patients with better control over chronic conditions can decrease emergency room visits and hospital stays, thereby reducing costs for their insurance providers.
  • Assured Revenue Stream: CCM provides another method of sustaining and growing your practice without adding additional facilities or an accompanying increase in necessary personnel.

Care Gaps  

Population health works to improve patient care across a group. Multiple metrics contribute to the data required for analyzing the health of a population. Your practice should have a population health manager who examines data collected by various modules. 
 
Care cap analysis offers one way to examine population health. Analyzing the health of your patient population makes finding areas for improving care, practice efficiency, and finances simpler. With population health monitoring, you can become a more efficient, effective practice. 
 
Why Track?  
Patient care gaps impact your practice and outcomes for your patients. Modules that gather data and analyze your patients’ care will help you find and fill gaps in care. Consequently, your patients have more complete care, and your practice will gain financial and time savings benefits. 

Better Care for Patients

Patients who have clear communication with their providers receive better care overall. They feel informed about their condition and treatment plan and can take active roles in their care between clinic visits. In fact, patients who feel more involved in their care have better overall outcomes, as multiple studies have shown over time.

Patient care is the heart of the medical profession. Closing care gaps lets you focus on bettering treatment methods and plans for your patients. Finding simple ways to improve care for all patients makes your practice more efficient

Faster Reimbursement for Your Practice

Third-party payers, such as Medicare or Medicaid, need clear, fast communications about patient care. Using digital tools that collect and securely share data with these payers reduces the time for reimbursements compared to filing paperwork. Plus, the digital formats for submitted Information do not have issues with unreadable handwritten notes or signatures.

Closing care gaps and monitoring population health metrics will become the standards for care reimbursement in the future. The trend started by the Centers for Medicare and Medicaid Services (CMS), will likely expand to private insurance companies. Taking charge now to collect and use population health data effectively will keep your practice ready for the future and faster reimbursements today.

Improved Population Health for All Your Patients

One way to close gaps in care is by scheduling one in-person appointment with each patient annually. This face-to-face care ensures that patients have the chance to discuss their health and for you to reduce care gaps in their treatment.

As you close the care gaps with your patients, you’ll also improve population health. Patients with better care require lower expenditures for their health care and improve the overall health of their population cohort. Closing care gaps helps all your patients from a population health perspective.

Financial Growth Opportunities

When you find care gaps, you may need to offer additional services to your patients. These provide you with a new revenue source that doesn’t require your practice to add new patients. Consistent income can allow your practice to grow financially, allowing you to focus your efforts less on making ends meet and more on improving patient care.

Clinical Quality Measures

Clinical quality measures (CQMs) give your practice the opportunity to showcase your exceptional level of care. These metrics assess your practice’s capacity for delivering patient-centric care that emphasizes quality. 

CMS uses these metrics to ensure that practices that accept Medicare and Medicaid meet best practices in treatment quality. The system tracks 270 metrics. Your practice must submit 60 percent or more of eligible instances for the measurements.  The benefits of incorporating this module into your practice include:


  • Enhanced Preventative Patient Care: With the data collection and public reporting mechanisms instituted by CMS, practices are incentivized to improve support for providing a culture of safety and reducing the levels of unnecessary care. Reducing reimbursement rates based solely on the quantity of care provided may eventually lead to making care more affordable for everyone. Patients will become more involved in their care, have better access to their records, and receive more motivation to take steps necessary to live a healthier life.


  • Improved Care Delivery: By using incentives to improve levels of care provided to patients, CMS is pushing forward with the objective of achieving a patient-focused era of medical care. They are working to encourage providers to change how care is given by building better teams, increasing coordination across providers and health care facilities, and directing more attention to population health.

  • Increased Bottom Line: The practice benefits financially in the long run when it achieves the ability to receive payment adjustments.

Unlock Tools to Examine Population Health Within Your Practice 

Your patients deserve quality care that follows best practices. Improve your practice operations to optimize their care by identifying care gaps. With data analysis tools to spot these gaps, your practice will have ways to improve care delivery and optimize finances. Fill out the form bellow and connect with our team to learn more about how you can implement population health tools to improve patient care quality and boost revenue. 

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