Chronic Care Management for Long-Term Care — Powered by ALIS + CCN Health

CCM for Long-Term Care with ALIS and MatrixCare

Many long-term care facilities use ALIS as their facility EHR while the ordering physician or medical director uses MatrixCare for their practice. This dual-EHR reality creates challenges for CCM programs — clinical data lives in two systems that don't natively talk to each other. CCN Health solves this by integrating with both systems simultaneously.

The Dual-EHR Challenge in Long-Term Care

In long-term care settings, it's common for:

• The facility to use ALIS for resident records, charting, and daily care documentation
• The physician to use MatrixCare for orders, billing, and clinical decision-making
• CCM data to be needed in both systems for complete clinical documentation

Without an integration bridge, nursing staff must manually enter data in both systems, leading to documentation gaps, billing delays, and clinical risk.

How CCN Health Bridges ALIS and MatrixCare

CCN Health's platform sits between both EHR systems, serving as a central hub for all CCM data:

1. Device data flows to CCN Health — Vital signs from monitoring devices are captured by the CCN Health platform
2. ALIS receives resident records — Vital signs, alerts, and care documentation sync to ALIS resident charts
3. MatrixCare receives clinical summaries — The ordering physician gets CCM reports, clinical observations, and billing-ready documentation in their MatrixCare workflow
4. Billing documentation routes correctly — Claims data goes to the billing entity (physician practice via MatrixCare) with supporting clinical documentation

Data Flow: ALIS ↔ CCN Health ↔ MatrixCare

Data Type	ALIS	CCN Health	MatrixCare
Resident Demographics	Source	Syncs	Receives
Vital Signs	Receives	Hub	Receives
Clinical Alerts	Receives	Generates	Receives
Care Plans	Shared	Coordinates	Shared
Billing Documentation	Reference	Generates	Primary
CCM Time Tracking	Reference	Tracks	Primary

Why This Matters for Long-Term Care

Sustained Monitoring

Continuous vital sign trending over long stays enables early detection of gradual health changes.

Hospitalization Prevention

Proactive alerts help clinical teams intervene before conditions deteriorate to emergency levels.

Documentation Continuity

Automated charting creates a continuous record that supports longitudinal care planning.

Billing Considerations for Dual-EHR CCM

In dual-EHR environments, billing typically flows through the physician practice (MatrixCare):

CPT Code	Reimbursement	Billing Entity	Documentation Source
99490	~$62/mo	Physician (MatrixCare)	CCN Health → MatrixCare
99491	~$83/mo	Physician (MatrixCare)	CCN Health → MatrixCare

CCN Health ensures all required documentation is routed to the correct system for compliant billing regardless of which entity submits the claim.

Frequently Asked Questions

Do both EHR systems get the same CCM data?

Both systems receive CCM data, but the content is tailored to each system's role. ALIS gets resident care documentation, while MatrixCare receives clinical summaries and billing records.

Who submits the Medicare claims?

Typically the physician practice bills through MatrixCare, with CCN Health providing all required documentation. The specific billing arrangement depends on your organization's structure.

Is there extra setup for dual-EHR integration?

CCN Health configures both integrations during the standard implementation period. The dual-EHR setup is part of our standard offering — no additional cost or extended timeline.