CCM for Long-Term Care
Chronic Care Management for Long-Term Care — Powered by athenahealth + CCN Health
Purpose-built CCM for Long-Term Care communities. CCN Health integrates directly with athenahealth to automate clinical workflows and capture every eligible reimbursement.
CCN Health provides a certified Chronic Care Management (CCM) integration with athenahealth designed specifically for long-term care facilities. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Chronic Care Management for Long-Term Care with athenahealth
Implementing CCM in long-term care settings requires an integration that understands both the clinical needs of residents requiring ongoing custodial and skilled nursing care, typically with chronic conditions requiring sustained management and the workflows of athenahealth. CCN Health bridges this gap.
Long-Term Care Challenges That CCM Addresses
- Providing consistent monitoring for residents with chronic conditions over extended stays
- Reducing avoidable hospitalizations and ER transfers
- Maintaining comprehensive care documentation over months or years
- Managing staffing constraints while ensuring clinical oversight
How It Works in Long-Term Care
- 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
- athenahealth Documentation — Care coordination notes and time logs sync to athenahealth automatically
- Billing Automation — Time tracking and documentation for CPT 99490/99491 generated automatically
Why Long-Term Care Facilities Choose CCN Health
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.
Revenue Growth
Medicare reimbursement creates new revenue streams without requiring additional clinical staff.
Devices for Long-Term Care CCM
| Device | Use Case | Resident 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 Long-Term Care
Chronic Disease Management
Monitor residents with conditions like heart failure, diabetes, COPD, hypertension. Trending data helps care teams adjust care plans before conditions deteriorate.
Transition of Care Support
When residents return from hospital stays, CCM enables closer monitoring during the critical post-discharge period.
Billing & Reimbursement in Long-Term Care
CCN Health automates Medicare CCM billing documentation for qualified residents:
| 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 resident: $62+
Frequently Asked Questions
Does CCN Health integrate with athenahealth for long-term care CCM?
Yes. CCN Health's certified athenahealth integration enables bi-directional data flow specifically designed for long-term care workflows.
What is the implementation timeline for long-term care?
Most long-term care facilities are fully operational within 4 weeks, including integration setup, nursing staff training, and device deployment.
How does CCM billing work in long-term care?
CCN Health automatically documents the required data for 99490, 99491. Time tracking and transmission records are captured for audit-ready Medicare billing.
Implementation for Long-Term Care
| Week | Activity |
|---|---|
| 1 | Discovery call and athenahealth configuration review |
| 2 | Technical integration setup and testing |
| 3 | Nursing staff training and device deployment |
| 4 | Pilot launch with select residents |
| 5+ | Full facility 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 Long-Term 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 Long-Term 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 athenahealth
Your program data flows directly into athenahealth — 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.
athenahealth
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 athenahealth so that RPM data flows directly into patient charts, reducing manual documentation and improving care coordination.
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.
RPM in long-term care provides continuous vital-sign monitoring that helps clinical staff detect changes early, reduce unnecessary hospitalizations, and improve quality metrics.
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 Long-Term Care?
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.