Chronic Care Management (CCM) is a Medicare-supported program that provides coordinated, ongoing care for patients with two or more chronic conditions, outside of traditional office visits. CCM covers non-face-to-face services that practices use to provide supplemental health education, follow up on health-related activities, and actively engage patients in pursuing improved health goals.
The target population is patients with two or more chronic conditions expected to last twelve months or longer, or until the patient's death. Common examples include diabetes, hypertension, COPD, heart disease, and depression — conditions that place patients at significant risk of death or functional decline and involve a high level of medical care and follow-up.
.jpg)
The case for CCM is compelling. Because 75–85 percent of the nation's health care dollars are spent on people with chronic conditions, the National Center for Chronic Disease Prevention and Health Promotion has identified chronic disease as the public health challenge of the 21st century. In response, CMS recognized CCM as a critical component of primary care in 2015 and adjusted the Medicare Physician Fee Schedule to encourage practices to provide more management services to Medicare patients with multiple chronic conditions.
For practices, the benefits go beyond patient outcomes. CCM provides another method of sustaining and growing your practice without adding additional facilities or an increase in necessary personnel, while providing additional resources and care for high-need patients. CCM also unlocks a meaningful revenue stream: Medicare reimburses providers for care coordination time spent between visits using established CPT codes.
The Amazing Charts CCM Platform
Amazing Charts provides a built-in CCM platform that integrates directly with your EHR workflow, turning your practice into a hub for ongoing care between visits. Rather than managing chronic conditions reactively, the platform gives your team the tools to be proactive.
.png){kind=icon}
Managing CCM: In-House vs. External Partnership
Once your practice decides to offer CCM, the next question is how to operationalize it. There are two primary models: managing the program with your own staff, or partnering with a specialized CCM services organization. Each approach has real advantages depending on your practice size, capacity, and goals.
Managing CCM In-House
Running CCM internally gives your practice full control over patient relationships and care coordination workflows. It works well for practices that have:
- Adequate clinical and administrative staff bandwidth
- An established patient population comfortable with regular outreach
- Internal expertise in CMS billing and compliance requirements
The tradeoff is real overhead. Managing a CCM program internally often requires hiring additional care coordinators, nurses, or administrative staff, and those staff members also need to be trained in chronic care management, regulatory compliance, and the technical aspects of billing and coding.
.png){kind=icon}
Partnering with an External CCM Provider
For many independent practices, outsourcing CCM to a specialized partner is the more practical and financially sound path. Outsourced CCM vendors are experts in chronic disease management, with resources dedicated to improving patient health and engagement, providing regular monitoring, consistent follow-ups, medication management support, and patient education.
External partners also reduce compliance risk: they ensure your practice remains compliant with Medicare guidelines, helping you avoid costly mistakes or penalties, and reducing the risk of claims denials, delays, and audits.
Perhaps most importantly, outsourcing your CCM program offers the flexibility and scalability necessary to adapt to variations in patient volume without compromising quality of care, something difficult to achieve with a fixed internal team.
Amazing Charts has vetted and partnered with two best-in-class CCM service organizations to make external partnership seamless for our users.
Our CCM Partners
Cosán
Amazing Charts has partnered with Cosán to provide virtual care management services that help practices improve patient outcomes while reducing overall costs.
The program combines dedicated Care Coordinators, personalized care plans, real-time health monitoring, and ongoing patient engagement between visits to deliver proactive, preventative care.
By addressing both clinical and non-clinical patient needs, the partnership helps reduce healthcare fragmentation and creates a more connected care experience.
The impact is measurable, one practice reported saving $5,000–$6,000 per patient after implementing the program.
Services offered: CCM, Behavioral Health Integration (BHI), Remote Patient Monitoring (RPM), Principal Care Management (PCM)
Esrun Health
Amazing Charts also partners with Esrun Health, a division of Harris Healthcare to deliver fully managed virtual care solutions tailored to each practice’s needs.
Their customized model combines CCM, RTM, RPM, BHI, and TCM into a seamless remote care program designed to improve patient engagement and streamline communication between care teams and patients.
With no additional software or staff required, Esrun Health provides a turnkey solution that handles enrollment, monthly check-ins, compliance reporting, and billing support, reducing administrative burden while ensuring Medicare compliance.
Practices using the program have reported 20% fewer hospitalizations, 30% higher medication adherence, and stronger patient satisfaction and retention.
Services offered: CCM, RPM, Remote Therapeutic Monitoring (RTM), BHI, Principal Care Management (PCM), Transitional Care Management (TCM)
Default Title
Amazing Charts has partnered with Cosán, the industry's leading healthcare organization creating new pathways to modern aging. Cosán delivers a preventative care coordination tool suite for CCM, BHI & RPM to help providers improve patient outcomes through the use of advanced technologies and expertly designed one-on-one personalized care between office visits. Cosán delivers team-based virtual care management, helping reduce fragmentation in healthcare by combining clinical expertise, non-clinical support, and intelligent technology for a seamless patient experience. Care Teams led by Care Coordinators support patients' behavioral, nutritional, and non-clinical needs, and real-time health data analysis flags rising health risks to providers so interventions can happen before conditions become urgent.
The CCM program pairs patients with a dedicated Care Coordinator and a Care Team to collaborate with their providers in creating personalized, disease-specific care plans, including disease-specific modules, symptom reporting, medication and scheduling support, patient education, and direct coordination with your practice staff.
The results speak for themselves. One Amazing Charts practice reported: "We're seeing the results — in a recent meeting with our ACO, they said, 'We've noticed that you've been saving us $5,000–$6,000 per patient, and it seems like this has been happening since the month of August.' We correlated this with when we started with Cosán and CCM."
Services offered
-
Chronic Care Management (CCM)
-
Behavioral Health Integration (BHI)
-
Remote Patient Monitoring (RPM)
-
Principal Care Management (PCM)
Default Title
Amazing Charts also partners with Esrun Health, a division of Harris Healthcare that brings deep clinical expertise and a fully managed approach to CCM. Esrun Health is on a mission to redefine remote care through a customized model of remote care services that blends CCM, Remote Therapeutic Monitoring (RTM), Remote Patient Monitoring (RPM), Behavioral Health Integration (BHI), and Transitional Care Management (TCM) for each client based on their specific practice needs.
Esrun Health's care coordination platform is designed to improve patient engagement and foster seamless communication between care teams and patients, with no additional software or staff required to implement the program. Their proactive approach is designed around your workflows, maximizing patient data and engagement while minimizing work for your team.
Esrun's full-service, turnkey CCM program helps practices improve patient outcomes, increase recurring revenue, and reduce administrative burdens, all while ensuring seamless compliance with Medicare guidelines. They handle everything from patient enrollment and monthly check-ins to compliance reporting and billing support.
Practices working with Esrun have seen 20% fewer hospitalizations with proactive care and early intervention, 30% higher medication adherence through monthly patient check-ins, and higher patient satisfaction and retention.
Services offered
-
Chronic Care Management (CCM)
-
Remote Patient Monitoring (RPM)
-
Remote Therapeutic Monitoring (RTM)
-
Behavioral Health Integration (BHI)
-
Principal Care Management (PCM)
-
Transitional Care Management (TCM)