PCM for Long-Term Care
Principal Care Management for Long-Term Care — Powered by MatrixCare + CCN Health
Purpose-built PCM for Long-Term Care communities. CCN Health integrates directly with MatrixCare to automate clinical workflows and capture every eligible reimbursement.
CCN Health provides a certified Principal Care Management (PCM) integration with MatrixCare designed specifically for long-term care facilities. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Principal Care Management for Long-Term Care with MatrixCare
Long-Term Care facilities face unique challenges managing resident health: providing consistent monitoring for residents with chronic conditions over extended stays and reducing avoidable hospitalizations and er transfers. CCN Health's PCM integration with MatrixCare addresses these challenges with automated monitoring, documentation, and billing.
Long-Term Care Challenges That PCM 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
- Condition Identification — Identify a single high-complexity chronic condition requiring ongoing management
- Specialist Care Plan — Develop condition-specific management plan with measurable goals
- Focused Monitoring — Disease-specific metrics tracked and trended over time
- MatrixCare Integration — Specialist coordination data and care plans sync with MatrixCare automatically
- Billing Automation — Time tracking for CPT 99424-99427 documented 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 PCM
| Device | Use Case | Resident Experience |
|---|---|---|
| Condition-Specific Devices | Targeted monitoring | Devices matched to the principal condition |
| Specialist Dashboard | Disease tracking | Trend views for condition-specific metrics |
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, PCM enables closer monitoring during the critical post-discharge period.
Billing & Reimbursement in Long-Term Care
CCN Health automates Medicare PCM billing documentation for qualified residents:
| CPT Code | Reimbursement | Requirements |
|---|---|---|
| 99424 | ~$70/mo | 30+ minutes of clinical staff time per month |
| 99425 | ~$56/mo | Each additional 30 minutes of clinical time |
| 99426 | ~$80/mo | 30+ minutes of physician/QHP time |
| 99427 | ~$64/mo | Each additional 30 minutes of physician time |
Monthly potential per resident: $70+
Frequently Asked Questions
Does CCN Health integrate with MatrixCare for long-term care PCM?
Yes. CCN Health's certified MatrixCare 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 PCM billing work in long-term care?
CCN Health automatically documents the required data for 99424, 99425, 99426, 99427. Time tracking and transmission records are captured for audit-ready Medicare billing.
Implementation for Long-Term Care
| Week | Activity |
|---|---|
| 1 | Discovery call and MatrixCare 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 MatrixCare
Your program data flows directly into MatrixCare — no exports, no manual entry, no disruption to your clinical workflow.
Specialist Data
Condition Monitoring, Referrals
AI-Powered Platform
Intelligent data routing, anomaly detection, and automated documentation — working behind the scenes.
MatrixCare
Charts & Care Plans
What Flows Between Systems
Patient Demographics
High-risk conditions, specialist data, and medications
Condition Tracking
Disease-specific metrics monitored and trended
Specialist Coordination
Referral data and specialist notes synchronized
Care Plans
Condition-specific treatment plans inform monitoring
Time Tracking
Care management minutes tracked for billing compliance
Billing Documentation
CPT 99424/99425/99426/99427 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
Principal Care Management (PCM)
2 billing codes
First 30 minutes of clinical staff time for PCM
~$70
Monthly
Each additional 30 minutes of PCM clinical staff time
~$54
Monthly (additional)
Common Questions
Frequently Asked Questions
Everything you need to know about implementation, billing, and clinical workflows.
Yes. CCN Health integrates with MatrixCare to deliver monitoring data into post-acute care workflows, supporting RPM and CCM programs across skilled nursing and senior living.
PCM focuses on patients with a single high-risk chronic condition, billed under CPT codes 99424 and 99425, covering care coordination and management services.
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 TeamGet Started
Ready to bring Principal 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.