CCM for CCRC
Chronic Care Management for CCRC — Powered by Epic + CCN Health
Purpose-built CCM for CCRC communities. CCN Health integrates directly with Epic to automate clinical workflows and capture every eligible reimbursement.
CCN Health provides a certified Chronic Care Management (CCM) integration with Epic designed specifically for ccrc campuses. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Chronic Care Management for CCRC with Epic
CCRC campuses face unique challenges managing resident health: managing monitoring across multiple care levels on one campus and maintaining continuity of data as residents transition between care levels. CCN Health's CCM integration with Epic addresses these challenges with automated monitoring, documentation, and billing.
CCRC Challenges That CCM Addresses
- Managing monitoring across multiple care levels on one campus
- Maintaining continuity of data as residents transition between care levels
- Standardizing protocols across independent, assisted, memory care, and skilled nursing
- Demonstrating value of the continuum model to prospective residents and families
How It Works in CCRC
- 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
- Epic Documentation — Care coordination notes and time logs sync to Epic automatically
- Billing Automation — Time tracking and documentation for CPT 99490/99491 generated automatically
Why CCRC Campuses Choose CCN Health
Continuum Coverage
One monitoring platform covers every care level — data follows the resident as acuity changes.
Transition Support
Continuous monitoring data informs care level transitions with objective health metrics.
Campus-Wide Insights
Aggregated data across all care levels supports operational planning and quality improvement.
Unified Billing
Single billing infrastructure handles Medicare reimbursement across all campus care settings.
Devices for CCRC 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 CCRC
Chronic Disease Management
Monitor residents with conditions like hypertension, diabetes, heart failure, COPD. Trending data helps clinical 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 CCRC
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 Epic for ccrc CCM?
Yes. CCN Health's certified Epic integration enables bi-directional data flow specifically designed for ccrc workflows.
What is the implementation timeline for ccrc?
Most ccrc campuses are fully operational within 4 weeks, including integration setup, care staff training, and device deployment.
How does CCM billing work in ccrc?
CCN Health automatically documents the required data for 99490, 99491. Time tracking and transmission records are captured for audit-ready Medicare billing.
Implementation for CCRC
| Week | Activity |
|---|---|
| 1 | Discovery call and Epic configuration review |
| 2 | Technical integration setup and testing |
| 3 | Care staff training and device deployment |
| 4 | Pilot launch with select residents |
| 5+ | Full campus 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 CCRC 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 CCRC Facilities Choose CCN Health
Purpose-built technology that fits your clinical workflows and drives measurable outcomes.
Seamless EHR Integration
How CCN Health Works Inside Epic
Your program data flows directly into Epic — 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.
Epic
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 Epic via secure APIs, enabling RPM device data and care management documentation to flow into Epic's enterprise health records.
CCN Health transmits device readings and care coordination notes to Epic through FHIR-based APIs, ensuring clinical data is available within existing Epic workflows.
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.
CCRCs use RPM across all levels of care—from independent living to skilled nursing—providing a consistent monitoring platform that follows residents as their care needs evolve.
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 TeamGet Started
Ready to bring Chronic Care Management to your CCRC?
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.