chronic Care Management

Improve patient communication and quality of care
leading to better outcomes for your patients.

What is Chronic
Care Management?

The care management of patients with two or more chronic conditions (asthma, diabetes, hypertension, etc.). To qualify for reimbursement a minimum of 20 minutes must be spent monthly on care coordination services which include tasks like patient outreach, medication reconciliations, and records collection.

20 Minutes Per Month

Our clinical care teams will use our dialer and technology platform to proactively reach out to patients to engage them in their wellness and to provide the necessary services and documentation required to meet the 20 minutes per month.

Certified Staff

Our clinical teams are comprised of licensed RNs, LPNs and CNAs. All of our staff are licensed in the state in which the patients reside to comply with state and federal regulations.

Access to Care

Our care teams are dedicated to your facility, meaning your patients won’t speak to different people each time we call, or they call in. Our team is accessible to patients at all times including 24/7 triage capabilities.

Chronic Care Management Services: Enhanced primary care
– better health for Patients –

The Centers for Medicare & Medicaid Services (CMS) recognizes care management as one of the critical components that contributes to better outcomes, as well as reduced spending.

Effective January 1, 2015, Medicare established CPT Code 99490 for remote telehealth monitoring. This non-face-to-face service provides an average of $43/month/patient reimbursement for Medicare patients with two or more chronic illnesses monitored remotely under this code.

In 2016, the CMS expanded the program to include Complex Chronic Care Management and Behavioral Health Integration & Management codes. This expansion confirms that CMS remains invested in care management programs as a clinical benefit to patients.

Care Facts

H3C Chronic Care Management Services

Approved Care Plans

At H3C we utilize individualized evidence-based care plans and submit for physician review and approval. These care plans are reviewed by our nurses on a regular basis and any suggested care plan changes or revisions will always be brought to the physician for approval prior to implementation.

Medication Reconciliations

Our clinically licensed staff performs a medication reconciliation with each patient which includes a review of all prescription drugs, over-the-counter medications and herbal supplements that the patient consumes. Any discrepancies between the patient’s records and the patient’s actions are immediately reported to the clinic.

Early Identification

In addition to reviewing medications, symptoms and vitals, we also ask open-ended, probing questions to help identify areas of potential patient decline.

Our team has been able to identify medication use errors, life-threatening vitals, suicidal ideations, and more, often weeks before the patient’s next follow-up appointment.

Goals Monitoring

At H3C we recognize that the patient’s personal goals often provide opportunities to increase compliance with the physician’s treatment plans and goals.

Therefore we track the patient’s progress on both their own goals as well as the physician’s goals for the patient.


Patients often experience barriers to care. Our care team is trained in many forms of patient questioning to ensure that barriers can be identified. We will review Social Determinants of Health (SDOH), general barriers to care, and unique observations like Social Isolation. The findings will be provided to the physician, so mitigations can be included in the treatment plans.

Earn Recurring Revenue

Complete the calculator below to estimate your gross revenue from Chronic Care Management Services.
After calculating your estimated revenue, view the table below for the expenses and program requirements that are part providing CCM.

Offering CCM to your most at risk patients just makes sense.
Are you ready for the added ramp up costs and program requirements to do it yourself?

The real cost of providing CCM

Providing Chronic Care Management Services will require additional staff. That’s a fact. Existing staff is already distracted with other tasks which can lead to inconsistent CCM services for patients. Clinics must have dedicated staff to support CCM, which means hiring and training personnel before they engage with patients.

On average, internal clinic programs that we have seen are able to support 30-50 patients per staff member.  Hiring a full-time nurse, between salary and benefits, could cost your clinic an additional $90,000 per year or more. This means the break-even per nurse is 174 CCM patients.

At H3C, we provide the dedicated clinical staff necessary to expand your services without creating additional expense for your clinic.

To find out more information on extending your services with our staff, contact H3C for a full services demo!

Due to the specific requirements of Chronic Care Management, your staff needs to be fully trained on the requirements relating to onboarding patients to the program, billable time rules, call documentation and coordination of care across several caregivers, clinics, and skilled care facilities.

At H3C, all of our staff receive structured in-depth and ongoing training for CCM. As a CMS Connected Care Partner, education on program compliance remains one of our highest priorities. By using our team to extend your staff, we alleviate the worries related to education and training.

To find out more information on our status as a CMS Connected Care Partner, contact H3C for a full services demo!

CMS will only reimburse for patients who have received a minimum of 20 minutes per month of Chronic Care Management Services. This means that all services provided require real-time tracking and documentation of time spent to ensure accuracy of charting and audit compliance.

If you are unable to spend 20 minutes per month, you can’t bill for reimbursement. If you spend more than 20 minutes per month, then the number of patients you need to cover your cost increases.

At H3C, we document the time spent on the phone, performing records collection, coordinating care with team members and more. We can generate full and detailed reports of time spent per patient per month for compliance and audit purposes. Additionally, H3C assumes the risk of non-billable patients meaning you aren’t responsible for the cost of spending less than 20 minutes with CCM patients.

To find out more information on the services that we provide, contact H3C for a full CCM demo!

Many clinics neglect to take into consideration how much time and effort the onboarding process involves. Patient onboarding for Chronic Care Management means extensive patient education. Patients must first understand the program, the potential cost to them, and how they can access their care coordinators.

Once patients have received and understood the program explanation and agreed to participate, records must be collected from all care team providers, initial CCM assessments must be performed and evidence-based, individualized care plans must be created.

At H3C, we provide the calling services required to educate, enroll, and onboard CCM patients. Our care team will collect records from all care providers, perform baseline assessments and identify and close care gaps. In addition, our nurse managers will draft individualized care plans for physician review and approval. We alleviate the burden to staff that might otherwise fall behind on duties or struggle to fulfill the requirements.

To find out more information on the services that we provide, contact H3C for a full CCM demo!

Clinics implementing Chronic Care Management must ensure access to care management services and ensure continuity of care with a designated practitioner or member of the care team.  These care team members must have secure access to the patient records and care plan.

At H3C, our care line is available 24/7 for patients. Our nurses can review care plans, educate patients, answer questions, triage patients and escalate to emergency services if needed. This removes the burden of 24/7 access for the provider who will now only be contacted after hours in the event that true, clinically-based escalation is required.

To find out more information on the access to care that we provide, contact H3C for a full services demo!

Most EHRs were not designed to be a comprehensive platform for patient engagement services including CCM. In addition, most telephone systems do not support important features that facilitate CCM delivery.

Many clinics do not have the tools required to manage a patient call schedule for a large population on a monthly basis. H3C has the right technology and training to make CCM implementation seamless including call scheduling/management, call recording, and standardized quality assurances practices.

To find out more information on the technology that we provide, contact H3C for a full services demo!

Implementing a CCM program will incur additional overhead costs such as:

  • Hiring & Training Staff
  • Technology Resources (Phones, Computers, etc.)
  • Additional Work Space

To find out more information on the additional costs that can arise, contact H3C for a DIY Proforma!

The requirements and management to support CCM may seem overwhelming.
When you partner with H3C, you can provide the benefit of  Chronic Care Management services to your patients without the distraction and risk

Is Your Practice Ready for
Chronic Care Management?

Download our free ebook on the benefit of offering CCM
to your patients without the distraction and without the financial risk

Real Patients Real Impact
The Red Flag

An existing patient described being disoriented and could not remember large blocks of time. The patient’s dedicated H3C nurse triaged the patient and identified that the patient was currently oriented x3.  The Nurse immediately contacted the doctor for a same day visit.  The doctor identified the patient had experienced a stroke. Due to social isolation the patient unfortunately had no one identify this during the event. The physician developed a treatment plan for prevention and the H3C team assisted the patient with overcoming his social isolation through locating appropriate community involvement opportunities.

CCM: More Than a Phone Call

An H3C care team member was reaching out to a patient to schedule an Annual Wellness Visit. The patient was very upset with news of a new disease.   The care team member explained the benefit of continuum of care with CCM. The conversation provided the patient with much needed support and guidance at a time when they otherwise felt very lost. The H3C team member provided education on their disease along with community resources. More importantly they provided an ear to the patient who very much needed just to talk with someone who would listen. The annual visit was scheduled and the patient requested CCM services just as the physician was recommending them.