Population Assessment
We analyze available patient information to help identify potential program populations and estimate operational opportunity.
Fully Managed Chronic Care Management
Your patients deserve care,not a monthly checklist.
MatterCCM helps healthcare organizations deliver structured, meaningful support to patients living with multiple chronic conditions.
We manage the operational work behind the program while keeping participating providers connected to the decisions, escalations, and information that require clinical attention.
From eligible population to active care program.
A successful CCM program requires far more than placing monthly calls.
Patients must be identified accurately. Enrollment must be explained clearly. Consent must be maintained. Care plans must reflect real needs. Every interaction must be meaningful. Medications, appointments, specialists, caregivers, community services, and transitions may need coordination. Activities must be documented consistently. Escalations must reach the right person. Billing teams need reliable information.
When no single operating structure owns those responsibilities, the program becomes fragmented.
We bring them together.
Full-Service CCM Scope
We manage the work before, during, and after every monthly interaction.
Eligibility Review
Potential participants are reviewed against the program criteria and client-defined clinical or payer requirements.
Patient Outreach and Education
Patients receive a clear, respectful explanation of the program, how it supports their relationship with the provider, what participation involves, and any applicable financial responsibility communicated by the practice.
Consent and Enrollment Support
Enrollment activity, patient decisions, follow-up needs, and exceptions are tracked through structured workflows.
Comprehensive Care Planning
Care plans are developed and maintained in alignment with available clinical information, provider requirements, patient goals, conditions, medications, functional needs, psychosocial considerations, and other relevant factors.
Monthly Care Management
Patient interactions are guided by the individual care plan and may address symptoms, goals, medications, appointments, referrals, preventive needs, barriers, recent encounters, transitions, and changes in condition.
Medication Support
Care teams can review medication understanding, identify potential discrepancies or adherence concerns, and route clinical questions according to approved protocols.
Care Coordination
We help organize communication and follow-through involving providers, specialists, pharmacies, facilities, caregivers, community resources, and other participants in the patient’s care.
Transition Support
When patients move between settings, the program can support follow-up, information continuity, medication understanding, appointment coordination, and appropriate escalation.
Clinical Escalation
Urgent, significant, or protocol-defined concerns are routed to designated clinical contacts using established pathways.
Documentation and Quality Review
Activities are documented within approved workflows and reviewed for completeness, consistency, and alignment with program requirements.
Billing Readiness
Completed activity is evaluated against agreed service and documentation controls before billing information is released or coordinated with the responsible billing team.
Program Reporting
Clients receive visibility into population opportunity, enrollment, patient engagement, completed activity, exceptions, escalations, quality findings, and operational performance.
Meaningful Engagement
Our interactions are designed to uncover and address information that mattersA completed call is not the same as completed care.
A weak CCM model optimizes for reaching the end of a script.
A strong model asks whether the patient’s care plan moved forward.
- Has anything changed since the previous contact?
- Does the patient understand the current treatment plan?
- Are medications being taken as intended?
- Are appointments, tests, referrals, or refills outstanding?
- Has the patient visited an emergency department or hospital?
- Are symptoms becoming more difficult to manage?
- Are mobility, transportation, food access, cognition, caregiving, or other barriers affecting the plan?
- Does the provider or another member of the care team need to become involved?
The objective is not simply to contact the patient.
The objective is to maintain continuity.
A Patient’s Month
What one month of care management involves.
Margaret is an illustrative patient, not a real one, but every circumstance in her month is a common one. Follow what the care team does between her visits, and where her doctor stays in charge.
Margaret, 78
Illustrative patient
- Conditions
Type 2 diabetes, high blood pressure, heart failure
A home blood-pressure cuff. A reading over her doctor’s limit gets a nurse’s call the same day. Day 6
- Medicines
Several daily, including a water pill
Reviewed by phone each month, which is how the skipped evening dose came to light. Day 2
- Home
Lives alone
A regular call from her care team, so a change is noticed by someone. Day 2
- Getting around
No longer drives
A ride arranged to her cardiology appointment. Day 20
- Pharmacy
12 miles away
Her new prescription delivered to her home. Day 7
- Family
One daughter, out of state
Appointment dates shared with her daughter, with Margaret’s permission. Day 20
- Day 2
The monthly check-in
Her care manager reviews her medicines by phone and learns she has been skipping her evening water pill because it keeps her up at night, and passes that to her doctor.
Lives alone, so nobody else would have noticed - Day 6
A reading above her limit
Her home blood-pressure cuff sends a reading above the limit her doctor set. A nurse calls her that afternoon, checks for symptoms, and escalates to the practice under its protocol.
- Day 7
Her doctor changes the plan
Her doctor adjusts the dose and moves the water pill to the morning. The care team arranges home delivery of the new prescription and walks her through the change.
Pharmacy 12 miles away, and she no longer drives - Day 14
Back within range
A week of readings inside her doctor’s limits. The escalation is closed and the outcome noted in her chart, so the next person to speak with her knows what happened.
- Day 20
An overdue referral, booked
A cardiology referral from earlier in the year was never scheduled. The care team books it, arranges a ride, and, with her permission, sends the date to her daughter.
Daughter lives out of state - Day 30
The month, closed properly
Time and activity are documented, her care plan is updated, and a summary reaches her chart for her doctor to review. Next month’s check-in is already scheduled.
Standard and Complex CCM
Complex-care configurations may includeThe level of care should reflect the level of complexity.
Not every eligible patient requires the same operating intensity.
MatterCCM can help organizations establish appropriate workflows for standard CCM and more complex patient populations.
- More detailed clinical review
- Higher-touch patient engagement
- Additional care-team involvement
- More frequent coordination
- Enhanced caregiver communication
- More intensive transition follow-up
- Condition-specific protocols
- Behavioral and social risk considerations
- Expanded escalation requirements
- Additional documentation and quality controls
Program configuration remains subject to provider direction, medical necessity, payer requirements, and the services selected.
Benefits to the Organization
Extend Your Clinical Reach
Maintain more structured contact with patients between scheduled encounters.
Reduce Staff Burden
Avoid placing population analysis, enrollment, monthly outreach, documentation, and program oversight entirely on existing personnel.
Improve Program Consistency
Establish repeatable workflows across patients, providers, locations, and care teams.
Strengthen Visibility
Give leadership a clearer view of participation, activity, exceptions, and operating performance.
Support Financial Sustainability
Create a more organized connection between care delivery, documentation, quality review, and billing readiness.
Build for the Future
Develop longitudinal-care infrastructure that can support broader value-based and population-health strategies.
What the Research Shows
What CCM has been shown to do, and how few patients receive it.
$74
slower growth in Medicare spending per patient per month for CCM recipients than for a matched comparison group over 18 months, net of the CCM fee.1
View source (opens in a new tab)47 fewer
hospitalizations per 1,000 beneficiaries over 12 months, comparing growth among CCM recipients with a matched comparison group. Emergency department visits: 23 fewer.2
View source (opens in a new tab)3.4%
of Medicare beneficiaries aged 65 and over with two or more chronic conditions received CCM in 2019, up from 1.1% in 2015.3
View source (opens in a new tab)
Sources
- Schurrer J, O’Malley A, Wilson C, McCall N, Jain N. Evaluation of the Diffusion and Impact of the Chronic Care Management (CCM) Services: Final Report. Mathematica Policy Research for the Centers for Medicare & Medicaid Services; November 2017. cms.gov↩
- Schurrer J, O’Malley A, Wilson C, McCall N, Jain N. Evaluation of the Diffusion and Impact of the Chronic Care Management (CCM) Services: Final Report. Mathematica Policy Research for the Centers for Medicare & Medicaid Services; November 2017. Table III.12. cms.gov↩
- Jang J, McCarthy EP, Olivieri-Mui B, et al. Use of chronic care management service among Medicare beneficiaries in 2015–2019. Journal of the American Geriatrics Society 2024;72(9):2730–2737. doi.org/10.1111/jgs.19066↩
Published industry research, not MatterCCM program results. Outcomes for any organization depend on its population, implementation and program design.
Patient Experience
Your provider remains the center of the relationship.
MatterCCM works as an extension of your participating healthcare organization.
Patients should understand that their care-management team is supporting the plan established with their provider—not replacing the provider or creating a separate source of care.
Communication is designed to beSee what a fully managed CCM program could look like for your organization.
We will evaluate your patient population, current workflows, clinical capacity, EHR environment, and operating goals.