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

Pulmonary Associates of Fredericksburg

For over 30 years, Pulmonary Associates of Fredericksburg (PAF) has served families in Fredericksburg, VA — as a proudly independent pulmonology practice with physicians who are free to make the best decisions for their patients. CCM helped PAF improve patient access, deliver proactive care to 1300 patients, drive $840k in annualized revenue at a 58% margin, and earn patient satisfaction scores of 9.6 out of 10.

On-Demand Webinar

Thriving Independently: Entrepreneurial Opportunities for Physician-Led Practices

How can independent practices navigate financial pressures, regulatory burdens, staffing challenges, and reimbursement complexities—all while preserving clinical autonomy? Managing partner Rohit Goyal, MD of Pulmonary Associates of Fredericksburg takes an entrepreneurial approach to practice leadership that helped him increase annual revenue by 15%—without increasing his workload.

On-Demand Webinar

Simplifying Compliance in Chronic Care Management

Whether you're new to CCM or looking to improve your program, compliance is critical. Joining us is Amanda Crouch, CPC, CPMA, CIC, CRC, Vice President of Operations at The Grant Group. With over 15 years of experience in healthcare coding, auditing, and revenue cycle management, Amanda is a leading expert in CCM compliance.

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.

TOOLKITS, WHITEPAPERS, AND ARTICLES

Article

What conditions qualify for Medicare Chronic Care Management (CCM?)

Many physicians — especially specialists — have questions about which chronic conditions are eligible for between-visit care under Medicare’s Chronic Care Management (CCM) program and what criteria patients must meet to be eligible...

Whitepaper

The Bridge to Value for Kidney Care

Which fee-for-service programs can help your practice fund the transition to value-based care, while building the operational and clinical muscles you’ll need for success?

Article

Stop doing between-visit work for free

Are your physicians burnt out? In February 2024, athenahealth released the results of their third annual Physician Sentiment Survey, conducted by Harris Poll. The findings were both disturbing and (sadly) expected...

Article

Population-scale care management is impossible – or is it?

Last week, I wrote about benchmarking a Chronic Care Management (CCM) program. Because Medicare’s CCM program is severely underpenetrated – only 3% of applicable providers are participating – many medical groups have never had the opportunity to see a scalable, financially sustainable program at work...

Article

How to benchmark your Chronic Care Management (CCM) program

Less than 3% of providers participate in Medicare’s Chronic Care Management (CCM) program — even though Medicare increased reimbursement by 54% in 2022. CCM compensates providers for all the between-visit care they currently provide for free to their patients with multiple chronic conditions. So why don’t more providers run CCM programs? It’s a question of scale...

Article

Neurologists have practice management on the brain (sorry, we had to)

Coming out of the NeuroNet Summit 2024 last week, one thing is clear: neurology leaders are actively seeking solutions to the industry-wide challenges putting their practices at risk...

Article

Are these 3 barriers keeping you from delivering better between-visit care?

Chronic Care Management can help medical groups deliver better care while creating a durable and profitable revenue stream — here’s how to overcome the most common barriers...

Article

Chronic Care Management (CCM) For Neurology

Neurologists provide extensive between-visit care to their patients with chronic conditions – but only 0.37% are earning fair compensation for that care through Medicare’s Chronic Care Management (CCM) Program...

Toolkit

Combating Margin Compression

How wilI your practice beat margin compression? Experts at Pinnacle and Phamily will help you understand margin pressures and identify, prioritize, and invest in margin expansion opportunities that can enhance your profitability in 2024 and beyond.

Have more questions? Check out our CCM FAQ.

want to learn more?

Talk to us

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.

Are you a patient? Click here to learn about Phamily for patients.

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.