Chronic Care Management Agent: Continuous Patient Support
Provides ongoing support for patients with chronic conditions (diabetes, hypertension, CHF, COPD)—monitoring symptoms, medication adherence, and lifestyle factors between visits.
Key Capabilities
- Patient Monitoring - Regular check-ins via SMS or phone (symptom tracking, weight, BP, glucose)
- Medication Adherence - Reminds patients to take meds, refill prescriptions
- Lifestyle Coaching - Sends tips for diet, exercise, stress management
- Escalation Protocols - Alerts provider if patient reports worsening symptoms
- Care Plan Management - Tracks goals, interventions, and outcomes
- Billable CCM - Generates documentation for Medicare CCM billing (99490, 99439)
- Remote Patient Monitoring - Integrates with RPM devices
- Engagement Analytics - Tracks patient participation and outcomes
Impact
Hospitalizations
-20-30%
Revenue (CCM)
$40-$60 PMPM
Patient Engagement
+60%
Quality Scores
Improved
Technical Details
Integration & Features
- RPM Integration
- Connects with remote patient monitoring devices
- Data Collection
- FHIR-based structured data capture
- Care Plans
- Condition-specific care plan templates
- Billing
- Automated CCM billing code generation (99490, 99439)
Security & Compliance
- HIPAA Compliant
- SOC 2 Type II Certified
- Real-time processing and logging
- End-to-end encryption
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