Chronic Care Management for Home Health — Powered by PointClickCare + CCN Health

CCM for Home Health with PointClickCare and Epic

Many home health agencies use PointClickCare as their facility EHR while the ordering physician or medical director uses Epic for their practice. This dual-EHR reality creates challenges for CCM programs — clinical data lives in two systems that don't natively talk to each other. CCN Health solves this by integrating with both systems simultaneously.

The Dual-EHR Challenge in Home Health

In home health settings, it's common for:

• The facility to use PointClickCare for patient records, charting, and daily care documentation
• The physician to use Epic for orders, billing, and clinical decision-making
• CCM data to be needed in both systems for complete clinical documentation

Without an integration bridge, clinical team must manually enter data in both systems, leading to documentation gaps, billing delays, and clinical risk.

How CCN Health Bridges PointClickCare and Epic

CCN Health's platform sits between both EHR systems, serving as a central hub for all CCM data:

1. Device data flows to CCN Health — Vital signs from monitoring devices are captured by the CCN Health platform
2. PointClickCare receives patient records — Vital signs, alerts, and care documentation sync to PointClickCare patient charts
3. Epic receives clinical summaries — The ordering physician gets CCM reports, clinical observations, and billing-ready documentation in their Epic workflow
4. Billing documentation routes correctly — Claims data goes to the billing entity (physician practice via Epic) with supporting clinical documentation

Data Flow: PointClickCare ↔ CCN Health ↔ Epic

Data Type	PointClickCare	CCN Health	Epic
Patient Demographics	Source	Syncs	Receives
Vital Signs	Receives	Hub	Receives
Clinical Alerts	Receives	Generates	Receives
Care Plans	Shared	Coordinates	Shared
Billing Documentation	Reference	Generates	Primary
CCM Time Tracking	Reference	Tracks	Primary

Why This Matters for Home Health

Between-Visit Monitoring

Continuous data capture fills the gaps between scheduled home visits with objective vital sign data.

Reduced Hospitalizations

Early alerts enable clinical response before conditions require emergency department visits.

Clinician Efficiency

Automated charting reduces documentation burden, allowing clinicians to focus on direct patient care.

Billing Considerations for Dual-EHR CCM

In dual-EHR environments, billing typically flows through the physician practice (Epic):

CPT Code	Reimbursement	Billing Entity	Documentation Source
99490	~$62/mo	Physician (Epic)	CCN Health → Epic
99491	~$83/mo	Physician (Epic)	CCN Health → Epic

CCN Health ensures all required documentation is routed to the correct system for compliant billing regardless of which entity submits the claim.

Frequently Asked Questions

Do both EHR systems get the same CCM data?

Both systems receive CCM data, but the content is tailored to each system's role. PointClickCare gets patient care documentation, while Epic receives clinical summaries and billing records.

Who submits the Medicare claims?

Typically the physician practice bills through Epic, with CCN Health providing all required documentation. The specific billing arrangement depends on your organization's structure.

Is there extra setup for dual-EHR integration?

CCN Health configures both integrations during the standard implementation period. The dual-EHR setup is part of our standard offering — no additional cost or extended timeline.