Who We Serve
ChronicCare partners with physicians in private, group practice, community health centers, or health systems to deliver comprehensive chronic care management (CCM), principal care management (PCM), remote patient monitoring (RPM), and transitional care management (TCM) services. By outsourcing these value-based services, providers can enhance patient engagement, reduce hospital readmissions, and increase billable revenue through Medicare-supported programs. ChronicCare simplifies care coordination so practices can focus on what matters most: delivering exceptional patient care.
Whether you are a single-provider family medicine practice or a physician group network, we help you grow Medicare revenue, improve patient outcomes, and reduce burnout-without increasing your workload. Our pharmacist-led care team handles time-consuming tasks like care planning, medication reconciliation, and patient follow-up, allowing you to focus on what you do best: practicing medicine.
We understand the unique needs, operational and billing requirements of FQHCs and RHCs, so we can help you launch and scale chronic care management initiatives and remote patient monitoring that keep your community healthy and generate new revenue streams with no demand on your staff. Our turnkey solution improves health outcomes, reduces hospitalizations, and addresses health disparities in underserved communities.
We help hospitals and their affiliated practices to extend care beyond discharge and outpatient visits, helping reduce readmissions, improve outcomes, and support value-based care initiatives. We help hospitals close care gaps by offering medication reconciliation, care plan development, and lifestyle coaching-particularly in the critical 30-day post-discharge period.
Specialty practices like endocrinology, cardiology, nephrology, gastroenterology, urology, and oncology can benefit from our care management services. We integrate with your workflow to support patients with chronic conditions-such as diabetes, heart failure, and gut diseases-through care planning, lifestyle coaching, and medication management. Improve adherence, reduce hospitalization, and generate new reimbursements.
Benefits of Value-Based Care (VBC)
Private Practices
VBC programs like CCM, RPM, and TCM create new billing streams through Medicare & other payors
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Enhanced patient engagement leads to stronger provider-patient relationships and higher satisfaction
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Data-driven care coordination and technology tools streamline workflows and reduce unnecessary in-office visits
Group Practices
Participation in ACOs or value-based contacts allows groups to benefit from cost savings​
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CCM enables full utilization of clinical staff-nurses, pharmacists, care managers-in support roles​
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Easier tracking & reporting of clinical outcomes boosts performance in quality incentive programs
FQHC & RHC
CCM promotes patient-centered interventions, helping address gaps in care for underserved populations
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VBC supports compliance with HRSA and UDS quality benchmarks, boosting eligibility for additional funding
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VBC encourages culturally competent care and better chronic disease management in vulnerable communities
Hospital Practices
Coordinated care post-discharge lowers 30-day readmissions rates and associated penalties
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VBC drives proactive care for high-risk patients, supporting health system goals
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Smooth handoffs between inpatient and outpatient settings improve continuity and patient outcomes
How it Works
STEP 1 - Identify patients​
Our team works with you to identify patients eligible (Medicare) for PCM, CCM and/or RPM services.
STEP 4 - Provide monthly care management​
Each month, our care team will call patients, update care plans, log time for billing, and proactively alert providers to potential issues which arise.
STEP 2 - Obtain consent to enroll patients​
Our team helps you obtain consent from patients. If patient hasn't been seen in 12 months, initiating visit is required prior to enrollment.
STEP 5 - Time tracking for accurate billing​
Our platform automatically logs time spent working on patient profile. Time tracking generates appropriate CPT code when threshold is reached.
STEP 3 - Create care plans ​
Virtual care team creates custom patient care plans using evidence-based guidelines. Physician can review and update or approve.
STEP 6 - Documentation for Billing​
We generate a report every month showing every CPT billable code for each each patient along with time spent.
