Chronic Care Management, Value Based Care

Chronic Care Staffing^SM is a nationwide provider of remote patient health services strictly following CMS service guidelines. We work with an array of clients ranging from small practices to large health systems. Working directly in the client EMR, our clinical team is scalable, ensuring a fast ramp up, high participation and low drop out patient enrollment program. CCS has developed industry leading documentation, population health initiatives and Value Based Reimbursement (VBR) calling protocols which helps optimize remote patient care as well as client reimbursement.

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Chronic Care Management(CCM, CPT 99490/G0511)

CCM is a Medicare/Medicare Advantage program designed to reduce unnecessary ER visits and hospitalizations. Patients are monitored in between office visits on a monthly basis. CCM can be significant while providing a platform to improve clinical outcomes and close gaps in care.

Health Risk Assessment (HRA) for Annual Wellness Visits(AWV, CPT G0438/G0439)

Annual Wellness Visits are an integral component of Value Based Care. Evidence suggests HRA use and follow up interventions can positively influence health behaviors. AWVs help reduce health disparities and improve health outcomes through identifying modifiable health risks.

Transitional Care Management(TCM, CPT 99495/99496)

TCM is intended to reduce potentially preventable readmissions and medical errors during the first 30 days following discharge from the acute care setting. Starting in 2021 CCM services are allowed to be billed concurrently with TCM.

Virtual Clinical Staff Augmentation

CCS can provide remote staff to augment your clinical team. CCS’s clinical staff (Multidisciplinary skilled nurses) can perform a wide variety of virtual duties while charting in your EMR in real time while identifying as a part of your practice.

Case Studies

Medication Adherence

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Patient Staisfaction

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What Our Clients are Saying

CCS does a fabulous job. We have gone a long way toward improving people’s health, simply by discovering the number of patients who were out of meds!! Patients comment that calls from action items sent by you to us are resolved quickly, adding to feeling you’re just down the hall.

Managing Partner and MD of large family practice

CCS clinical approach has already produced great result. We ran a quick report on diabetes and it shows that the patients enrolled in CCM are more likely to have received an updated A1c Screening as well as their diabetic retinopathy and nephropathy screening. Also 78% of the diabetics in the CCM program are controlled compared to 68% of our total population of diabetics.

Chief Clinical Officer of a Federally Qualified Health Center (FQHC)

I feel we have a great line of communication. The numbers reflect many patients are enrolling. I was concerned many patients would be resistant due to the previous experiences but it does not appear to be a problem. It is a pleasure for me to work with your team.

Program Administrator of a Medical Center

Our patients love the CCS nursing staff. They have coordinated with our providers seamlessly. We have been very satisfied with our working relationship with Chronic Care Staffing.

Chief Medical Officer of a Regional Family and Internal Medicine Center

Chronic Care Staffing does a fabulous job getting so many patients on the phone. We have gone a long way toward improving people’s health, simply by discovering the number of patients who were out of meds!! Overall feedback from our patients is great. They are all convinced you are sequestered in rear of building. They comment that calls from action items sent by you to us are resolved quickly, adding to feeling you’re just down the hall (confidence).

Fabulous job