Chronic Care Management Services for Ongoing Patient Support
Patients living with multiple chronic conditions require consistent follow up and coordinated care. Cedar Health provides structured Chronic Care Management services that ensure patients remain supported between office visits.
Continuity of Care Without Added Complexity
Our program includes monthly care coordination delivered by trained healthcare professionals who collaborate with providers to monitor patient progress. We help track care plan adherence, manage medications, reinforce preventive strategies, and address emerging concerns before they escalate.
Chronic Care Management improves continuity of care while reducing the burden on in office teams. Patients benefit from regular communication and guidance, while providers gain greater visibility into long term treatment progress.
Core Components
Monthly patient check ins
Comprehensive medication reconciliation
Personalized care plan documentation
Preventive care reminders
Health education and lifestyle guidance
Reduce Hospitalizations and Improve Satisfaction
By maintaining consistent contact, we help reduce avoidable hospitalizations and improve patient satisfaction. Chronic Care Management also supports quality reporting initiatives and value based care performance metrics.
When integrated with Remote Patient Monitoring and Care Coordination services, providers can deliver a fully connected care experience.
Chronic Care Management FAQ
What is Chronic Care Management?
Chronic Care Management is ongoing, coordinated care for patients living with two or more chronic conditions. It includes a personalized care plan, monthly check ins between visits, medication reconciliation, preventive care reminders, and coordination with specialists and community resources.
How does Chronic Care Management billing work?
CCM is billed monthly to Medicare and many commercial payers under CPT codes 99490 for the first twenty minutes of non face to face clinical staff time, 99439 for each additional twenty minutes, and 99487 and 99489 for complex CCM. The patient must consent to enrollment, and Cedar Health documents every minute of care time so the practice can bill with confidence.
Who is eligible for Cedar Health's CCM program?
Patients with two or more chronic conditions expected to last at least twelve months, or until the end of life, that place the patient at significant risk of decline. Common examples include hypertension with diabetes, heart failure with COPD, and chronic kidney disease with obesity.
What conditions does Cedar Health support?
Cedar Health supports hypertension, diabetes, congestive heart failure, COPD, chronic kidney disease, obesity, and other conditions that benefit from continuous coordination. CCM pairs with Remote Patient Monitoring so clinical decisions are grounded in current home readings.
Does Chronic Care Management add work for our staff?
No. Cedar Health clinical staff carry out the monthly outreach, documentation, and care plan updates, then report the results back to the practice. Providers stay in control of clinical direction without adding administrative hours.