Chronic Care Management

CareCentra Enables Physicians to Better Engage and Nudge Patients with Chronic Conditions through Life’s Critical Stages.

According to the Center for Disease Control (CDC), about half of all adults—117 million people—have one or more chronic health conditions. Two of three adults have two or more chronic health conditions. Seven of the top 10 causes of death in 2013 were due to chronic disease. Two chronic conditions, heart disease and cancer, together accounted for nearly 48% of all deaths. And eighty-four percent of all health care spending is provided for individuals who have one or more chronic medical conditions.


Chronic conditions include both physical and behavioral health conditions that last a year or more, and require ongoing medical care and /or limit physical abilities.


Medicare’s push for value based care programs


  • The cost of managing chronic diseases such as cancer, diabetes, hypertension, heart disease, and mental illness can be overwhelming.
  • By offering incentives to physicians to manage Medicare patients with multiple chronic illnesses, the Centers for Medicare & Medicaid Services (CMS) sees an opportunity to improve the quality and cut costs.
  • Medicare’s new Chronic Care Management (CCM) program represents a major step toward incentivizing physicians to keep patients healthy between office visits.
  • Alternative payment models that are now being designed and launched by CMS emphasize the shift from episodic care (fee for service) to varying degrees of shared risk between providers and payers (value based care models)



  • Leverage a powerful Natural Language Processing (NLP) Analytics toolset to properly identify your eligible CCM patient population.
  • Develop Individualized care plans with high-touch intervention outreach to generate the right message or reminder (nudges) at just the right time.
  • Automate nudges and triggers – specific, targeted stimuli – utilizing a variety of communication modalities like IVRs, emails and text messaging, to gently persuade, or challenge beneficiaries to act differently.
  • Access an intelligent care navigator workflow engine with work list, task and nudge management tools to track appointments, nudges, correspondence, interactions, and barriers. Care teams automatically notified regarding noncompliance.

  • Care Plan Evaluation Manager allows care teams to compare progress against established goals and interventions while providing the ability to make adjustments.
  • Deliver bi-directional data transfer to and from your Certified EHR.
  • Track time spent on prescription management/medication reconciliation and non-face-to-face services for the beneficiary including time spent coordinating care with other clinicians, community resources, and caregivers.
  • Generate audit reports to prompt billing for CPT Code 99490.
  • Automate and simplify the consent process – beneficiaries can consent via portal, email, or electronically in your office.

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