Monthly care coordination for patients managing two or more chronic conditions — the ongoing work that keeps care plans current.
Chronic Care Management (CCM) is at least 20 minutes each month of non-face-to-face care coordination for patients with two or more chronic conditions — medication reconciliation, care plan updates, and consistent communication that keeps small issues from becoming missed diagnoses. CHMS runs this end-to-end on your behalf.
Patients with 2+ chronic conditions.
Individualized & kept current.
20+ minutes of coordination.
Provider stays informed.
Every CHMS CCM program runs on RCMS — our proprietary care intelligence platform. Instead of a generic monthly script, RCMS asks condition-specific questions, scores every response algorithmically, generates a targeted action item for the coordinator, and fires a real-time alert to the provider when a patient's risk crosses a threshold.
Patients aren't just monitored — they're mapped to a defined pathway for their diagnosis, so non-improvement on a treatment plan gets caught and escalated automatically, not discovered three months later at the next visit.
See How RCMS WorksLet's talk about which patients are eligible for CCM.
