PCM for Home Health
Principal Care Management for Home Health — Powered by PointClickCare + CCN Health
Purpose-built PCM for Home Health communities. CCN Health integrates directly with PointClickCare to automate clinical workflows and capture every eligible reimbursement.
CCN Health provides a certified Principal Care Management (PCM) integration with PointClickCare designed specifically for home health agencies. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Principal Care Management for Home Health with PointClickCare
Home Health agencies face unique challenges managing patient health: monitoring patients between home visits when clinicians are not present and detecting health deterioration early enough to prevent hospitalization. CCN Health's PCM integration with PointClickCare addresses these challenges with automated monitoring, documentation, and billing.
Home Health Challenges That PCM Addresses
- Monitoring patients between home visits when clinicians are not present
- Detecting health deterioration early enough to prevent hospitalization
- Coordinating care across multiple home health team members
- Ensuring device compliance when staff cannot supervise daily use
How It Works in Home Health
- 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
- PointClickCare Integration — Specialist coordination data and care plans sync with PointClickCare automatically
- Billing Automation — Time tracking for CPT 99424-99427 documented automatically
Why Home Health Agencies Choose CCN 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.
Care Coordination
All team members see the same data, improving handoff quality and continuity.
Devices for Home Health PCM
| Device | Use Case | Patient 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 Home Health
Chronic Disease Management
Monitor patients with conditions like heart failure, COPD, diabetes, post-surgical. Trending data helps care teams adjust care plans before conditions deteriorate.
Transition of Care Support
When patients return from hospital stays, PCM enables closer monitoring during the critical post-discharge period.
Billing & Reimbursement in Home Health
CCN Health automates Medicare PCM billing documentation for qualified patients:
| 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 patient: $70+
Frequently Asked Questions
Does CCN Health integrate with PointClickCare for home health PCM?
Yes. CCN Health's certified PointClickCare integration enables bi-directional data flow specifically designed for home health workflows.
What is the implementation timeline for home health?
Most home health agencies are fully operational within 4 weeks, including integration setup, clinical team training, and device deployment.
How does PCM billing work in home health?
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 Home Health
| Week | Activity |
|---|---|
| 1 | Discovery call and PointClickCare configuration review |
| 2 | Technical integration setup and testing |
| 3 | Clinical team training and device deployment |
| 4 | Pilot launch with select patients |
| 5+ | Full agency 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 Home Health 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 Home Health Facilities Choose CCN Health
Purpose-built technology that fits your clinical workflows and drives measurable outcomes.
Seamless EHR Integration
How CCN Health Works Inside PointClickCare
Your program data flows directly into PointClickCare — 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.
PointClickCare
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 has a direct integration with PointClickCare, allowing vital-sign data from RPM devices to flow automatically into resident charts without manual entry.
Device readings are transmitted to CCN Health's platform and then pushed into PointClickCare via API, appearing alongside existing clinical documentation for a unified workflow.
PCM focuses on patients with a single high-risk chronic condition, billed under CPT codes 99424 and 99425, covering care coordination and management services.
Home health agencies use RPM to monitor patients between visits, receive real-time alerts for concerning readings, and document care coordination to support billing and compliance.
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 Home Health?
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.