NEW TOOLKIT: Getting Started with Chronic Care Management

Chronic Care Management (CCM) makes proactive care profitable

Support your patients with consistent, high-quality care between visits. Phamily makes it fast and easy to get started.

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Between-visit care improves outcomes for patients with chronic conditions

Chronic Care Management (CCM) lets practices get fair compensation for this between-visit work. With Phamily, you can scale the same high-quality, consistent care to 10x more patients than traditional methods.

Reduced hospitalizations

Better self-management

Lower total cost of care

4 hours

to get everything up and running

90%

monthly patient engagement — averaging 3.4 times per month

$700K

annual revenue per 1,000 patients

50%

profit margin to reinvest in your practice

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Stop playing phone tag with your patients

Bring order to the chaos of ad hoc triage calls, medication refills, and chart updates. CCM gives medical practices a framework to operationalize between-visit care — and get paid for it.

“Phamily far surpassed our expectations. Our CCM program is now a major profit center."

Amela RasketicDirector of Operations at Chicago Cardiology Institute

“I wish we could offer this program to all of our patients. The way it’s improved our ability to care for patients in-between their visits is exceptional.”

Dana BuiePractice Manager at The Endocrine Center

"I'm thrilled with text-based CCM, provided by Phamily; it made enrollment easy and now delivers care that patients love."

Julie MobleyCEO of Cullman Internal Medicine

Chronic Care Management (CCM) can transform your practice for the better

Deliver higher quality care

Streamline administrative tasks

Get fair compensation for between-visit work

Drive $700,000 annual revenue for every 1,000 patients enrolled

What is the difference between APCM vs. CCM?

Both Chronic Care Management and Advanced Primary Care Management compensate medical practices for between-visit work. Medicare uses these fee-for-service programs to reward providers who pursue value-based outcomes. However, there are important differences between the two programs, including which patients qualify and what activities are required to bill.

Launch your CCM program in just 4 hours

With Phamily’s industry-leading CCM platform and turnkey staffing, even the busiest practice can implement CCM, as onboarding takes just 4 hours. And for providers who prefer to keep things in-house, our AI copilot gives each care manager the tools they need to support 10x more patients with consistent, high-quality care.

Expert implementation — we’ve onboarded 100s of practices just like yours and have setup down to a fine art
Easy enrollment — most practices see 40% enrollment of eligible patients without an office visit
High engagement — Phamily drives 80%+ engagement with patient satisfaction scores that exceed 9/10
White-glove support — whether you choose turnkey staffing or build an in-house program, with CCM from Phamily you never have to go it alone

Explore our CCM Resources

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CUSTOMER STORIES

Case Study

KCCGA’s Strategy to Slow Chronic Kidney Disease Progression

After implementing initiatives to succeed in the value-based Kidney Care Choices model, the team at Kidney Care Center of Georgia (KCCGA) saw Chronic Care Management (CCM) as the next evolution to help patients under both fee-for-service and value-based models.

Case Study

The Neurology Center’s “Easy” Path to Chronic Care Management

The Neurology Center operates without any clinical support staff, but a turnkey solution enabled them to quickly launch Phamily CCM for 650+ patients within the first 2.5 months — no hiring or training required.

Case Study

Eastern Connecticut Hematology & Oncology

ECHO’s patients had diverse needs that required personalized care, but scaling between-visit care seemed impossible. A turnkey Connected Care service line helped them scale for better patient care and documentation.

Case Study

DENT Neurologic Institute

DENT’s growing nursing team still couldn’t keep up with patient needs between visits, until they started texting through Phamily Connected Care.

On-Demand Webinar

Chronic Care Management for Oncology

Cancer patients need significant care and support between visits. Oncology providers may balk at implementing Chronic Care Management (CCM): too expensive, for too few patients. But innovative cancer centers with Integra Connect are scaling high-quality, profitable CCM programs across 1000s of patients — and seeing transformative outcomes.

On-Demand Webinar

Empower Your Oncology Patients – and Practice – with Chronic Care Management

The ECHO team, led by Dr. Kapur, explain how they launched their Chronic Care Management program, share the positive impact CCM has had on their oncology patients and practice, and answer questions from a live audience.

Case Study

Nephrology Associates of Kentuckiana

Ramsay Nassar, MD sees increased prescription compliance, reduced hospitalization, and higher overall engagement from his practice’s CCM program.

On-Demand Webinar

Dent Live Q&A

Katie Ross, the Director of Clinic Operations at DENT Neurologic Institute, took questions from other neurology practice leaders about how DENT launched their Chronic Care Management (CCM) program with Phamily.

On-Demand Webinar

Balancing Kidney Care

Jennifer Huneycutt, CPA, CMPE explains how to match patients to programs for success in FFS and VBC.

TOOLKITS, WHITEPAPERS, AND ARTICLES

Toolkit

Getting Started with Chronic Care Management (CCM)

To take advantage of the new Advanced Primary Care Management (APCM) reimbursement for supporting patients with between-visit care, providers must meet 4 practice-level capabilities and perform 6 care management activities.

Article

From Burnout to Balance: The Unfair Reality of Neurology Compensation & How to Take Control

At this year’s NeuroNet Pro Annual Summit, one conversation stood out: Neurologists are being compensated unfairly. The numbers prove it, but even more compelling were the discussions with real physicians—people like you—who are feeling the weight of administrative burdens, low reimbursements, and financial pressures that make it harder to stay independent...

Whitepaper

Advanced Primary Care Management vs. Chronic Care Management

The introduction of Medicare APCM presents new opportunities for medical practices to receive fair reimbursement for the between-visit work they are already doing, but which fee-for-service program is right for your organization?

Whitepaper

Staff a scalable, profitable Chronic Care Management program for your neurology practice

Neurology practices that launch Connected Care programs see immediate demand from patients - often more than 1000 of them in the first 48 hours. The good news? Phamily CCM helps reduce the staff you need and find a staffing model that works for you - whether your practice is big or small.

Article

What’s Your Chronic Care Management (CCM) Compliance Strategy?

"Compliance is a key foundation for any successful Chronic Care Management program," explains Amanda Crouch, CPC, CPMA, CIC, CRC. Crouch is the VP of Operations at The Grant Group, a leader in healthcare revenue cycle management (RCM)...

Article

The Critical Questions Your APCM Plan Needs to Answer

Across the country we see increasing excitement about Medicare’s new Advanced Primary Care Management (APCM) program. Done well, APCM could be transformative for primary care practices and their patients. APCM provides fee-for-service reimbursement for providers to deliver high-value, proactive care across entire populations...

Article

To Succeed at APCM, Create Patient Value

Medicare will begin reimbursing providers for Advanced Primary Care Management (APCM) in 2025, and many providers are trying to decide whether to take advantage of this program. Will you be able to operate cost-effectively? What does it mean to provide “24 x 7 access”?

News

Integra Connect Teams Up with Jaan Health and Sweeten Health to Advance Chronic Care Management for Oncology

[WEST PALM BEACH, October 16] — Integra Connect, a leader in value-based, precision medicine solutions for specialty care, today announced a strategic collaboration with the leading chronic care management and proactive care company Jaan Health and innovative care management provider Sweeten Health.

Article

Chronic Care Management for Oncology Patients

Sarah had her first cigarette when she was 13. For the past few years, she has struggled with Chronic Obstructive Pulmonary Disease (COPD) and cardiovascular disease. And today, you held her hand and told her that she has Non-Small Cell Lung Cancer (NSCLC)...

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Whether you want to learn more about Chronic Care Management (CCM), understand staffing options, or demo the Phamily platform, our experts are here to help.

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Consistent care, fewer calls

Replace hundreds of monthly phone calls with weekly personalized text check-ins that patients love.

Work smarter, not harder

Headache-free auto-documenting care management, smart care plan templates and follow-up protocols.

CCM at significant scale

Enroll 1,000+ patients in 60 days. Not a dead-end side project that goes nowhere fast.