Monthly Clinical Oversight for Your Most Complex Residents.
Monthly Clinical Oversight for Your Most Complex Residents.
CCM provides comprehensive care plans, medication management, and early identification of decline for residents with multiple chronic conditions — with 24/7 access and transition support. Care coordination, aligned to HEDIS and STAR quality measures.
Structured Monthly Care for Complex Residents
Our CCM program provides monthly clinical oversight for residents with multiple chronic conditions — delivering comprehensive care plans, medication management, and early identification of decline. We build tailored plans, ensure regular follow-ups, and provide 24/7 access for urgent needs and support during care transitions.
Our clinicians bridge your residents, your SNF team, and their providers — reducing avoidable hospitalizations by addressing issues before they escalate. Missed follow-ups, overdue screenings, and unresolved referrals are tracked to completion, directly strengthening documentation and supporting quality measures tied to HEDIS and STAR.
Personalized Comprehensive Care Plans
Tailored to each resident's conditions, reviewed and updated as circumstances evolve — not left static between provider visits. Every enrolled resident receives a plan that reflects their current clinical picture.
Medication Management & Follow-Ups
Regimen reconciliation, interaction flagging, and adherence support for residents on complex polypharmacy. Our clinicians ensure nothing falls through the cracks between provider visits.
24/7 Urgent Care Access & Transition Support
Continuous availability for urgent clinical needs and coordination during any transition between care settings — reducing avoidable hospitalizations by addressing issues before they escalate.
Care Gap Closure Aligned to Quality Measures
Missed follow-ups, overdue screenings, and unresolved referrals tracked to completion — directly supporting HEDIS and STAR ratings and strengthening your facility's quality profile.
Which Residents Qualify for CCM?
- SNF residents with two or more chronic conditions (hypertension, diabetes, COPD, heart failure, CKD, etc.)
- Medicare Part B beneficiaries
- Conditions expected to last at least 12 months or placing the resident at risk of acute exacerbation
- Facilities seeking to improve HEDIS, STAR, and QIP quality measures
- Resident must provide written consent to enroll
Add CCM to Your Facility
Stronger continuity of care, fewer avoidable complications, and meaningful reductions in the hospitalizations that erode both resident wellbeing and facility reimbursement.
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