CCM for Memory Care
Chronic Care Management for Memory Care — Powered by ALIS + CCN Health
Purpose-built CCM for Memory Care 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 memory care communities, bridging both ALIS and athenahealth systems. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
CCM for Memory Care with ALIS and athenahealth
Many memory care communities use ALIS as their facility EHR while the ordering physician or medical director uses athenahealth 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 Memory Care
In memory care settings, it's common for:
- The facility to use ALIS for resident records, charting, and daily care documentation
- The physician to use athenahealth for orders, billing, and clinical decision-making
- CCM data to be needed in both systems for complete clinical documentation
Without an integration bridge, care staff must manually enter data in both systems, leading to documentation gaps, billing delays, and clinical risk.
How CCN Health Bridges ALIS and athenahealth
CCN Health's platform sits between both EHR systems, serving as a central hub for all CCM data:
- Device data flows to CCN Health — Vital signs from monitoring devices are captured by the CCN Health platform
- ALIS receives resident records — Vital signs, alerts, and care documentation sync to ALIS resident charts
- athenahealth receives clinical summaries — The ordering physician gets CCM reports, clinical observations, and billing-ready documentation in their athenahealth workflow
- Billing documentation routes correctly — Claims data goes to the billing entity (physician practice via athenahealth) with supporting clinical documentation
Data Flow: ALIS ↔ CCN Health ↔ athenahealth
| Data Type | ALIS | CCN Health | athenahealth |
|---|---|---|---|
| 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 Memory Care
Contactless Monitoring
Xandar Kardian radar sensors capture vitals without any wearables — ideal for residents who remove devices.
Wander Detection Support
Presence sensing and alert capabilities complement existing wander management systems.
Clinical Trending
Longitudinal data helps clinical teams correlate behavioral changes with physiological indicators.
Billing Considerations for Dual-EHR CCM
In dual-EHR environments, billing typically flows through the physician practice (athenahealth):
| CPT Code | Reimbursement | Billing Entity | Documentation Source |
|---|---|---|---|
| 99490 | ~$62/mo | Physician (athenahealth) | CCN Health → athenahealth |
| 99491 | ~$83/mo | Physician (athenahealth) | CCN Health → athenahealth |
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 athenahealth receives clinical summaries and billing records.
Who submits the Medicare claims?
Typically the physician practice bills through athenahealth, 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.
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 Memory Care 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 Memory Care 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.
Yes. CCN Health offers sensorless monitoring options ideal for memory care, where residents may not be able to operate traditional devices. Passive sensors track vitals without requiring any action from the resident.
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