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

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.

On-Demand Webinar

How I started a profitable, patient-focused CCM program

A physician leader explains how his mid-sized nephrology practice delivers superior patient care, keeps up with inflation, and demonstrates outcome performance to payers.

TOOLKITS, WHITEPAPERS, AND ARTICLES

Article

Phamily’s Public Comment on the CMS Request for Information; Health Technology Ecosystem

We can’t talk about an evolution in health tech without talking about an evolution in payment models and financial policy.

Article

Mental Health and Chronic Condition Management

When we think about managing chronic conditions, we often focus on medications, labs, and lifestyle changes. But mental health plays a critical (and sometimes overlooked) role. Anxiety, depression, and emotional stress can make it harder for patients to stick to treatment plans, attend appointments, and stay motivated. That’s why integrating mental health into chronic condition care isn’t just beneficial—it’s essential.

Article

Why Cutting Costs Won’t Save Your Independent Practice

Medicare reimbursement rates have declined 33% over the last 20 years while practice costs have skyrocketed. Every year, financial challenges further squeeze independent practices. It’s only natural that managing partners and practice administrators start scrutinizing expenses and slashing costs. But cost-cutting alone won’t protect a practice.

Article

Good Care Shouldn’t Begin in the Emergency Room

Over a decade ago, my father suffered a heart attack. In the weeks that followed, he received an overwhelming amount of care: hospital visits, specialists, medications, and lifestyle changes that were suddenly top priorities. But what struck me most was the glaring absence of professional support before his heart attack.

Article

Why Independent Practices Need to Survive — and Thrive

Patients can receive great care in many different settings, from a large national health system to the office of a single rural physician. So why is there so much concern about the decline of independent practices?

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.

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.