The Centers for Medicare and Medicaid Services (CMS) established Chronic Care Management (CCM) rules and reimbursement in 2015 to help provide support for patients with multiple chronic conditions in-between their provider visits to reduce Medicare expenditure and improve health outcomes. The research proves that CCM works when implemented by providers.

  • 20 min of non face-to-face clinical staff time (used as: coordination, coaching, or other eligible services)
  • Comprehensive Care Planning (includes but not limited to: Problem list, treatment and medication management plan, goals, community services ordered, periodic revision and more)
  • 24/7 access to care (means to address urgent needs regardless of time, can be done via telephone)
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CCM with urCare

Our solution is standard CCM service integrated with professional Health Coaching and Caregiver support. urCare Health Coaches partner with Caregivers (paid or family member) to optimize resources in and around a patient’s life. Time spent with patients between visits (CCM 20min clinical staff) vary greatly provider to provider; ours is spent coaching, coordinating and monitoring. Services include:

  • Dedicated Health Coach to provide resources, accountability, behavior changing activities such as SMART action planning and more.
  • We optimize Caregiver support (family members, home health aides, ADH staff members). Caregiver contribution (input and support) greatly increase adherence, patient quality of life, while reducing Medicare expenditure.
  • Cultural concordance can influence adherence. Careful consideration is given when pairing coaches with members.
  • A Turnkey solution that includes patient monitoring through our dOR [digital Observation and Reporting] software. Easy and cost effective start up.
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  • Quality Metrics that reflect value-based care model
  • Improved adherence through self-management education and support
  • Case management caseload support
  • Patient tracking and monitoring between visits through caregiver or self-reporting
  • Effective care plans supported by dedicated health coaches as an extension of provider objective
  • Affordable and easy system assimilation
  • Increase revenue to sustain growth of practice
Contact us to start our care management solutions, to request pricing information, or to speak with our experts.