CCM for Memory Care
Chronic Care Management for Memory Care — Powered by Epic + CCN Health
Purpose-built CCM for Memory Care 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 memory care communities. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Chronic Care Management for Memory Care with Epic
Memory Care communities face unique challenges managing resident health: monitoring residents who remove, lose, or cannot operate wearable devices and detecting health changes in residents who cannot self-report symptoms. CCN Health's CCM integration with Epic addresses these challenges with automated monitoring, documentation, and billing.
Memory Care Challenges That CCM Addresses
- Monitoring residents who remove, lose, or cannot operate wearable devices
- Detecting health changes in residents who cannot self-report symptoms
- Managing elopement risk alongside health monitoring
- Correlating behavioral changes with physiological indicators
How It Works in Memory 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
- 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 Memory Care Communities Choose CCN Health
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.
Family Peace of Mind
Continuous monitoring reassures families their loved ones receive attentive, data-driven care.
Devices for Memory 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 Memory Care
Chronic Disease Management
Monitor residents with conditions like Alzheimer's disease, vascular dementia, hypertension, diabetes. Trending data helps memory 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 Memory 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 Epic for memory care CCM?
Yes. CCN Health's certified Epic integration enables bi-directional data flow specifically designed for memory care workflows.
What is the implementation timeline for memory care?
Most memory care communities are fully operational within 4 weeks, including integration setup, care staff training, and device deployment.
How does CCM billing work in memory 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 Memory Care
| 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 community 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 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 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.
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 TeamGet Started
Ready to bring Chronic Care Management to your Memory 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.