Top 7 Features of Chronic Care Management Software

CCM program allows patients to get quality care services from healthcare specialists remotely, anywhere, and steadily under adequate medical supervision. Today six in ten adults in America live with at least one chronic disease (an estimated 133 million Americans – nearly half the population – expected to reach 170 million by 2030), and four in ten adults have more than two chronic diseases.

To effectively implement a CCM program, one must need software that supports most essential features. There are numerous CCM software with various features. This article will discuss the top 7 features of Chronic Care Management software that one must look for in a software.

1. Patient Information Management

– Streamlined Patient Records

Chronic care management (CCM) streamlines patient medical records by integrating electronic health records (EHRs) with remote monitoring devices and other technologies. This allows healthcare providers to access real-time patient data, track progress, and make informed care decisions.

– Comprehensive Health History

CCM helps collect a comprehensive health history of the patient’s medical conditions, medications, allergies, and other health-related factors. This information is used to create a personalized care plan that helps the patient manage their chronic conditions and improve their overall health.

– Secure Data Storage

In the CCM solution, patient data is encrypted at rest and in transit, so unauthorized individuals cannot read it. It protects the data from unauthorized access by blocking incoming and outgoing traffic that does not meet specific security criteria. Access controls are used to restrict who can access patient data. Only authorized individuals, such as healthcare providers, can access the data.

2. Care Plan Creation and Management

– Patient-Centric Care Plans

Patient-centered care plans are a key feature of chronic care management Software. Care plans are created with the patient’s input and focus on their needs, preferences, and goals. The plan is reviewed and updated regularly to reflect the patient’s changing needs. The plans include specific, measurable, achievable, relevant, and time-specific (SMART) goals for the patient to work towards.

– Task Assignment and Tracking

CCM software allows care team members to create new tasks and assign them to other team members. Tasks can be assigned based on the individual’s skills and expertise, as well as the urgency and importance of the task. The task tracking feature allows care team members to track the status of tasks and ensure they are completed on time. It is achieved by setting tasks’ due dates and receiving notifications for the overdue tasks. 

– Goal Setting and Progress Monitoring

With the help of CCM programs, providers can set SMART goals for patients, track their progress toward those goals, and make adjustments as needed. It helps ensure that patients are on track to achieve their health goals and that care providers provide the most effective care possible.

3. Patient Engagement and Collaboration

– Secure Messaging

One of the most essential features of CCM software is secure messaging. It allows patients to communicate with their providers and be in touch with the care team. Also, providers can reach out to patients whenever needed.

– Multi-Provider Coordination

CCM software’s Multi-Provider Coordination (MPC) features allow organizations to manage and coordinate care across multiple providers, such as hospitals, clinics, and caregivers. It improves care quality, reduces costs, and improves patient outcomes.

– Patient and Care Team Interaction

CCM offers regular communication, shared decision-making, patient education, and self-management support. This ensures that patients receive the care they need to manage their chronic conditions effectively. This feature helps patients better understand their condition, make informed decisions about their care, and take an active role in managing their health.

4. Patient progress & vital tracking 

– Vital Sign Tracking

Vital sign tracking in CCM software includes monitoring critical vital signs such as blood pressure, blood glucose, weight, and oxygen saturation. These data are used to assess a patient’s health status, identify changes in their condition, and make necessary adjustments to their care plan. 

– Symptom Reporting

CCM can track and report symptoms like pain, fatigue, and mood changes. This information is used to assess the patient’s condition and make necessary adjustments to their treatment plan. The symptom reporting features can be integrated with other chronic care management tools, such as patient portals and remote monitoring devices. It allows healthcare providers to track patient’s symptoms over time and make more informed decisions about their care.

– Real-time Alerts

Real-time alerts in chronic care management are notifications that are sent to providers or patients when there is a change in a patient’s health status that could indicate a problem. These alerts can be based on various factors, such as abnormal vital signs, missed medication doses, or changes in laboratory value. It improves patient outcomes by allowing providers to intervene early and prevent complications.

5. Billing and Documentation

– Automatic CPT allocation

Automatic CPT allocation features initially identify patients who meet the criteria for CCM services using their electronic health records. It calculates the number of minutes of clinical staff time that are billable for CCM services to each patient. Additionally, it generates the appropriate CPT codes for CCM services offered to the patient using the CPT code book. 

– Comprehensive Reporting and Analytics

CCM offers a comprehensive reporting of patient-level data such as patient demographics, diagnoses, medications, and test results. It also provides detailed information on the patient’s care goals, interventions, and progress. Providers, patients, and payers can get a report on the time spent on CCM activities and the associated charges. Reporting tools assist in analyzing the data to identify trends and patterns. 

6. Integration with EHR/EMR Systems

– Seamlessly integrate with multiple EHRs

CCM software seamlessly integrates with multiple EHR systems using the EHR Integration Bridge, allowing for the smooth exchange of electronic health information from other systems. Integration with EHRs eradicates the need for manual data entry, scales down administrative burdens, and improves data accuracy. Providers can approach real-time patient information straight from the EHR, facilitating timely interventions.

– Pull Patient Information & Documents

EHRs assist in successfully pulling patient demographics, contact information, and past medical history in no time. It seamlessly fetches diagnosis reports, medications, test results, and imaging studies such as X-rays and MRIs. EHR helps providers to check their prescriptions against patient allergies and drug interactions. It reduces errors, ultimately improving patient outcomes.

– Push Patient information & Billing Reports

EHR systems generate and send patient information and billing reports to designated recipients such as patients, providers, and payers. It pushes reports on billing data, such as patient charges, payments, and refunds, to the payer. It helps in tracking billing trends and identifying areas of improvement. It also allows healthcare organizations to manage their relationships with pharmacies, including tracking prescriptions, managing refills, and resolving billing issues.

7. Medication Management

– Medication Tracking

Medication tracking can help patients achieve better health outcomes by ensuring they take medication consistently and correctly—recording patient medications, including prescription and over-the-counter drugs, dosages, and frequency of administration. 

– Prescription Renewal Reminders

Prescription renewal reminders help patients stay on top of their medication needs by sending automatic reminders when prescriptions are due to be renewed. It also provides educational resources about medication adherence and helps patients connect with their care team. This reduces the risk of complications for patients with chronic conditions.

– Adverse Interaction Alerts

Adverse Interaction Alerts (AIAs) in CCM help in identifying and preventing potential drug interactions. It includes checking for drug-drug interactions, drug-food interactions, and drug-laboratory test interactions. It also provides alerts for potential interactions based on the patient’s medication list, medical history, and laboratory test results.


The CCM program improves the quality of care for patients with chronic diseases. Implementing a CCM program can be a difficult task but with good CCM Software with essential features you will be able to implement CCM programs effectively and efficiently. Also with good CCM software, it’s easy to track and bill for time spent by the provider. 



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