Care Management - Coordinated
at Home
Coordinated Care Management (CCM) by CCMS brings a proactive, patient-centered approach to healthcare, focusing on enhancing access to in-home care for patients who need it most. Our model leverages the latest technology and evidence-based practices to improve patient outcomes, reduce hospital readmissions, and create cost savings for providers. By offering comprehensive support in chronic care, behavioral health, and advanced care planning, CCMS delivers a full spectrum of coordinated services directly to patients.
The Four Pillars of Coordinated Care
Our CCM approach is built on four foundational components that ensure continuity and quality in care:
Transitional Care Management
Smoothly guiding patients through their care transitions to minimize hospital re-admissions.
Chronic Care Management
Supporting patients with chronic conditions through long-term care coordination (Learn more about chronic care management on CMS.gov).
Behavioral Health
Integrating behavioral health support into primary care to address the full scope of patient wellness.
Advanced Care Planning
Helping patients and families make informed decisions about their long-term care needs.
For a deeper look into the structure of care management, explore the CMS Coordinated Care Landing Page and watch Connected Care videos on the benefits of coordinated services.
Benefits for Providers
CCMS empowers providers to deliver high-quality care while experiencing meaningful cost savings and access to exclusive CMS benefits. Through comprehensive support and care coordination, we reduce the administrative burden for physicians, allowing them to focus more on their patients and less on paperwork. Providers gain:
Cost Savings
Reducing the need for hospital readmissions through proactive care lowers overall healthcare costs.
Increased Access to CMS Benefits
Eligibility for CMS incentives and performance-based payments, which reward quality care.
Impact on Patient Care
At CCMS, we believe in providing accessible, in-home care management to those who need it most, especially for patients facing barriers to consistent healthcare access. Our model focuses on reducing preventable readmissions and emergency room visits by coordinating care across various specialties and ensuring patients receive the care they need, when and where they need it.
In-Home Nursing Care Beyond Telemedicine
What sets CCMS apart is our commitment to providing real, hands-on, in-home nursing care. Our dedicated team of nurses and healthcare professionals go directly to patients’ homes, offering personal care and support that extends beyond remote monitoring. By providing face-to-face care, our team ensures a level of engagement and quality that elevates patient outcomes, minimizes hospital readmissions, and enhances the overall patient experience.