CCM for Home Health
Chronic Care Management for Home Health — Powered by ALIS + CCN Health
Purpose-built CCM for Home Health communities. CCN Health integrates directly with ALIS to automate clinical workflows and capture every eligible reimbursement.
CCN Health provides a certified Chronic Care Management (CCM) integration with ALIS designed specifically for home health agencies. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Chronic Care Management for Home Health with ALIS
Implementing CCM in home health settings requires an integration that understands both the clinical needs of patients receiving skilled nursing or therapy services in their homes, often managing chronic conditions between agency visits and the workflows of ALIS. CCN Health bridges this gap.
Home Health Challenges That CCM Addresses
- Monitoring patients between home visits when clinicians are not present
- Detecting health deterioration early enough to prevent hospitalization
- Coordinating care across multiple home health team members
- Ensuring device compliance when staff cannot supervise daily use
How It Works in Home Health
- Patient Enrollment — Identify Medicare patients with 2+ chronic conditions and obtain consent
- Care Plan Creation — Develop comprehensive care plan addressing all chronic conditions
- Monthly Coordination — Regular check-ins, medication reconciliation, and care plan updates
- ALIS Documentation — Care coordination notes and time logs sync to ALIS automatically
- Billing Automation — Time tracking and documentation for CPT 99490/99491 generated automatically
Why Home Health Agencies Choose CCN Health
Between-Visit Monitoring
Continuous data capture fills the gaps between scheduled home visits with objective vital sign data.
Reduced Hospitalizations
Early alerts enable clinical response before conditions require emergency department visits.
Clinician Efficiency
Automated charting reduces documentation burden, allowing clinicians to focus on direct patient care.
Care Coordination
All team members see the same data, improving handoff quality and continuity.
Devices for Home Health CCM
| Device | Use Case | Patient Experience |
|---|---|---|
| Care Coordination Platform | Multi-condition management | Centralized dashboard for all chronic conditions |
| Medication Tracking | Adherence monitoring | Automated refill reminders and reconciliation |
| Secure Messaging | Patient communication | HIPAA-compliant messaging for monthly check-ins |
Clinical Benefits for Home Health
Chronic Disease Management
Monitor patients with conditions like heart failure, COPD, diabetes, post-surgical. Trending data helps care teams adjust care plans before conditions deteriorate.
Transition of Care Support
When patients return from hospital stays, CCM enables closer monitoring during the critical post-discharge period.
Billing & Reimbursement in Home Health
CCN Health automates Medicare CCM billing documentation for qualified patients:
| CPT Code | Reimbursement | Requirements |
|---|---|---|
| 99490 | ~$62/mo | 20+ minutes of clinical staff time per month |
| 99491 | ~$83/mo | 30+ minutes of physician/QHP time per month |
Monthly potential per patient: $62+
Frequently Asked Questions
Does CCN Health integrate with ALIS for home health CCM?
Yes. CCN Health's certified ALIS integration enables bi-directional data flow specifically designed for home health workflows.
What is the implementation timeline for home health?
Most home health agencies are fully operational within 4 weeks, including integration setup, clinical team training, and device deployment.
How does CCM billing work in home health?
CCN Health automatically documents the required data for 99490, 99491. Time tracking and transmission records are captured for audit-ready Medicare billing.
Implementation for Home Health
| Week | Activity |
|---|---|
| 1 | Discovery call and ALIS configuration review |
| 2 | Technical integration setup and testing |
| 3 | Clinical team training and device deployment |
| 4 | Pilot launch with select patients |
| 5+ | Full agency rollout and optimization |
Discovery call — we learn your workflows, EHR setup, and resident population.
CCN's AI engine configures optimal alert thresholds and EHR data mapping around your facility's patterns.
Go live with AI-powered monitoring, automated documentation, and billing — your team stays focused on care.
No one-size-fits-all templates. Every integration is configured for how your Home Health actually operates.
Book a Discovery CallAI-Powered Alerts
Pattern recognition catches changes early
Smart Workflows
Automated routing and documentation
Automated Compliance
Real-time audit trail and billing validation
Advanced intelligence working behind the scenes — faster processing, smarter alerts, effortless documentation.
Technology that stays in the background — so care stays in the foreground.
Why CCN Health
Why Home Health Facilities Choose CCN Health
Purpose-built technology that fits your clinical workflows and drives measurable outcomes.
Seamless EHR Integration
How CCN Health Works Inside ALIS
Your program data flows directly into ALIS — no exports, no manual entry, no disruption to your clinical workflow.
Care Coordination
Calls, Assessments, Care Plans
AI-Powered Platform
Intelligent data routing, anomaly detection, and automated documentation — working behind the scenes.
ALIS
Charts & Care Plans
What Flows Between Systems
Patient Demographics
Chronic conditions, medications, and problem lists from your EHR
Care Plan Updates
Treatment plans and goals sync bi-directionally
Contact Logging
Phone calls and check-ins documented with timestamps
Medication Reconciliation
Current medication lists kept in sync across platforms
Time Tracking
Care management minutes tracked for billing compliance
Billing Documentation
CPT 99490/99491 records generated automatically
“Every reading, every alert, every care plan update — available across all your programs. One integration, unlimited use cases.”
Infrastructure
Medicare Billing
Automated Medicare billing documentation — every qualifying encounter captured and coded.
Medicare Billing
Chronic Care Management (CCM)
3 billing codes
First 20 minutes of clinical staff time for CCM services
~$62
Monthly
Each additional 20 minutes of CCM clinical staff time
~$47
Monthly (additional)
First 30 minutes of physician/QHP time for complex CCM
~$83
Monthly
Common Questions
Frequently Asked Questions
Everything you need to know about implementation, billing, and clinical workflows.
Yes. CCN Health integrates with the ALIS platform so that RPM readings sync directly into resident records, streamlining clinical workflows for senior living communities.
CCN Health transmits device data to ALIS through a secure API, ensuring vitals are available to caregivers inside the EHR they already use every day.
CCM is a Medicare program that reimburses providers for non-face-to-face care coordination for patients with two or more chronic conditions, billed under CPT codes 99490, 99439, and 99491.
Home health agencies use RPM to monitor patients between visits, receive real-time alerts for concerning readings, and document care coordination to support billing and compliance.
Most facilities are fully operational within 2–4 weeks. CCN Health handles device provisioning, EHR integration setup, staff training, and ongoing clinical support.
Still have questions? We're happy to walk you through anything.
Talk to Our Team
Get Started
Ready to bring Chronic Care Management to your Home Health?
See how CCN Health can improve resident outcomes, preserve independence, support family engagement, and generate new Medicare revenue — all within the EHR your staff already uses.