Chronic Care Management

Helping providers effectively manage their most vulnerable patients.

Smartlink CCM is part of our single platform solution for delivering Medicare’s Care Management programs and also includes AWV, TCM, and CoCM.

A successful Chronic Care Management (CCM) program requires more than people to make the monthly calls and technology to track and document time. The three critical success factors often missing are providing value to patients in every call, truly improving the quality of care, and an efficient workflow. These factors are critical to getting and keeping patients in the program, impacting quality measures, and running it in a profitable way.

Smartlink CCM can help.

Maintain Higher Patient Retention

Guided dialog helps ensure meaningful discussions with patients

Help Patients Get

What They Need

Target preventative care, social determinants, and quality measures

Get Paid for Work You Already Do

Easily track all the work being done by staff between visits towards CCM time

Drive Meaningful Conversations with Your Patients with Smartlink CCM

Smartlink CCM was designed by a nurse and physician based on two decades of experience managing the care of 1.5 million Medicare and Medicaid patients. Key features of the platform include:

  • Condition specific, evidenced based patient talk tracks that guide meaningful bi-directional dialogue with patients

  • Customizable clinical triggers and alerts

  • Out-of-the box standards based integration with certified EHRs

  • Scheduling and task management

  • Automatic time tracking

The Chronic Care Management software application by Smartlink displayed on a laptop screen.

Integrate with Your EHR

Smartlink leverages interoperability standards for out-of-the-box integration with over 90 EHRs. Deeper integration is also available to automatically send new orders and updated C-CDAs to the CCM platform. Additionally, once the service has been provided, the care plan with relevant forms can be added to the patient record, and a billable encounter can be created in the EHR.

Five Medicare Programs. One Cloud-based Platform.

Offer Medicare’s Annual Wellness Visit (AWV), Chronic Care Management (CCM), Behavioral Health Integration (BHI), Collaborative Care Management (CoCM), and Transitional Care Management (TCM) services using a unified, modular platform. Begin with one program and integrate others gradually as required, ensuring flexibility and scalability to meet evolving needs.

Providers

A father holding his daughter during a telehealth visit with a doctor.

Proactively care for your patients while creating a new revenue stream for the practice.

Service Providers

A father holding his daughter during a telehealth visit with a doctor.

Maintain a high level of productivity and customer satisfaction as you grow.

ACOs

A father holding his daughter during a telehealth visit with a doctor.

Support your member providers in reducing the cost of care for attributed patients.