CCM for Skilled Nursing
Chronic Care Management for Skilled Nursing — Powered by MatrixCare + CCN Health
Purpose-built CCM for Skilled Nursing communities. CCN Health integrates directly with MatrixCare to automate clinical workflows and capture every eligible reimbursement.
CCN Health provides a certified Chronic Care Management (CCM) integration with MatrixCare designed specifically for skilled nursing facilities. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Chronic Care Management for Skilled Nursing with MatrixCare
Skilled Nursing facilities face unique challenges managing resident health: managing high-acuity patients with multiple comorbidities and reducing 30-day hospital readmission rates. CCN Health's CCM integration with MatrixCare addresses these challenges with automated monitoring, documentation, and billing.
Skilled Nursing Challenges That CCM Addresses
- Managing high-acuity patients with multiple comorbidities
- Reducing 30-day hospital readmission rates
- Meeting CMS quality measures and star ratings
- Maintaining survey readiness with comprehensive documentation
How It Works in Skilled Nursing
- 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
- MatrixCare Documentation — Care coordination notes and time logs sync to MatrixCare automatically
- Billing Automation — Time tracking and documentation for CPT 99490/99491 generated automatically
Why Skilled Nursing Facilities Choose CCN Health
Readmission Prevention
Continuous monitoring during the critical post-acute window reduces hospital readmissions and improves quality scores.
Quality Measures
Objective vital sign data supports CMS quality reporting and star rating improvement efforts.
Survey Readiness
Comprehensive, timestamped records provide audit-ready documentation for state and federal surveys.
Acute-Level Monitoring
Continuous vital sign capture supports the higher-acuity clinical needs of skilled nursing residents.
Devices for Skilled Nursing 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 Skilled Nursing
Chronic Disease Management
Monitor residents with conditions like post-surgical recovery, heart failure, pneumonia, COPD exacerbation. 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 Skilled Nursing
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 MatrixCare for skilled nursing CCM?
Yes. CCN Health's certified MatrixCare integration enables bi-directional data flow specifically designed for skilled nursing workflows.
What is the implementation timeline for skilled nursing?
Most skilled nursing facilities are fully operational within 4 weeks, including integration setup, nursing staff training, and device deployment.
How does CCM billing work in skilled nursing?
CCN Health automatically documents the required data for 99490, 99491. Time tracking and transmission records are captured for audit-ready Medicare billing.
Implementation for Skilled Nursing
| 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 Skilled Nursing 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 Skilled Nursing 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.
Care Coordination
Calls, Assessments, Care Plans
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
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 MatrixCare to deliver monitoring data into post-acute care workflows, supporting RPM and CCM programs across skilled nursing and senior living.
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.
Skilled nursing facilities use RPM to continuously monitor residents' vitals, enabling early detection of decline, reducing hospital transfers, and supporting compliance with quality reporting requirements.
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 Skilled Nursing?
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.