This resource is intended to assist home based medical care providers with effectively managing Chronic Care Management (CCM) services, inclusive of guidance on how to identify eligible patients with multiple chronic conditions, initiate appropriate visits for assessment and consent, document patient consent, record and update patient information in certified Electronic Health Record (EHR) systems, develop and maintain electronic care plans, facilitate care transitions between healthcare providers and settings, and coordinate care with home-and community based clinical service practitioners, ensuring comprehensive and patient-centered care delivery while adhering to billing guidelines and patient consent requirements. Refer to CMS guidelines for full details and requirements.
