Chronic Care Management that actually gets done.

Operationally sound CCM programs that improve continuity of care without overwhelming staff.

Operational Outcomes & Program Impact

Operational Outcomes

  • Earlier risk detection outside visit windows
  • Fewer “unknowns” between check-ins
  • Better patient engagement without added staff time

Financial & Program Impact

  • Supports higher sustained enrollment
  • Improves documentation quality and continuity
  • Reduces staff follow-up overhead per patient

Where This Fits

  • Complements existing CCM workflows
  • No replacement of clinical decision-making
  • No billing interference or code dependency

Designed to strengthen programs already billing CMS-supported care management codes.

Who This Helps Most

  • Clinical Teams: Earlier signals without alarm fatigue—visibility into patient status between visits
  • Operations: Fewer check-ins, cleaner workflows, and better time documentation for billing
  • Leadership: Stronger programs without staffing expansion—scalable chronic care delivery

What CCM Solves

CCM supports patients with multiple chronic conditions through ongoing care coordination, medication management, and proactive outreach — outside of face-to-face visits.

Heart Failure

Ongoing medication management and symptom monitoring.

Diabetes

Regular check-ins on glucose control and lifestyle factors.

COPD

Symptom tracking and exacerbation prevention.

Hypertension

Medication adherence and blood pressure oversight.

How StillWell Health Supports CCM

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Patient Eligibility Identification

Workflows to identify and enroll patients who qualify for CCM.

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Monthly Care Coordination

Structured processes for consistent monthly outreach and documentation.

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Time Tracking Support

Live logging aligned to CMS billing requirements with full audit trails.

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Patient Engagement

Outreach, reminders, and touchpoints that keep patients connected.

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EHR Integration Options

Integration with existing workflows or lightweight parallel deployment.

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Analytics & Reporting

Track enrolled patients, time spent, revenue, and care outcomes.

Who This Is For

Primary Care Practices

Managing Medicare patients with multiple chronic conditions.

Rural Health Clinics

Needing sustainable revenue and patient engagement between visits.

FQHCs

Serving complex populations with limited care management staff.

Organizations Struggling to Sustain CCM

Programs that started but stalled due to workflow or staffing issues.

Ready to launch CCM that lasts?

Let's discuss your patient population and how CCM fits your practice operations.