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Tag: Clinical

Chronic Care Management (CCM) Provider Checklist - 2026

CCM Providers Checklist

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

Transitional Care Management (TCM) Face-To-Face Visit Requirements - 2026

TCM F2F Documentation Requirements

This resource is intended for home-based primary care (HBPC) providers and practice staff and defines the 2026 face-to-face documentation requirements for Transitional Care Management (TCM) Face-To-Face visits and serves as a reference when creating visit templates or building components into an Electronic Health Record (EHR). The content was gathered utilizing Centers for Medicare & Medicaid

Transitional Care Management (TCM) Interactive Contact Requirements - 2026

TCM Interactive Contact Requirements

This resource is intended for home-based primary care (HBPC) providers and practice staff and defines the 2026 requirements for the interactive contact required of clinical staff during the Transitional Care Management (TCM) period and serves as a reference when creating workflows or templates for outreach. The content was gathered utilizing Centers for Medicare & Medicaid

Remote Patient Monitoring - 2026

Remote Patient Monitoring

This resource is designed to guide house call programs in the use of remote patient monitoring services to care for their patients following the expansion and highlighted need for telemedicine as a result of the COVID-19 pandemic.  

Navigating Care Models: Comparing APCM & CCM for Optimal Practice Benefits - 2026

This resource serves as a comparative guide to support healthcare providers in evaluating and selecting between Advanced Primary Care Management (APCM) and Chronic Care Management (CCM). It outlines structural, operational, and reimbursement differences while helping organizations determine which model aligns best with their goals for home-based primary care (HBPC), care coordination, and patient outcomes.

Home-Based Medical Care: Telehealth Guidelines & Coding Requirements - 2026

Telehealth for Home Health

A comprehensive resource designed to provide guidance to home-based medical care programs in the use of telehealth services to care for their patients with the expansion of reimbursement opportunities post-pandemic. All content reflects 2025 updates and was gathered utilizing Centers for Medicare & Medicaid Services (CMS) guidelines. In this course, you will learn about possible

Home-Based Medical Care: Superbill Worksheet - 2026

Superbill Worksheet

A comprehensive list of the primary services that a home-based medical care practice would bill and submit for reimbursement. Includes CPT® codes, location of service (if applicable), service descriptor, 2026 wRVU, 2026 Medicare National Fee Schedule Payment, and precalculated 85% of Medicare allowable payment (NP/PA). This information allows programs to estimate revenue, create an internal

Home Based Medical Care Advanced Coding Opportunities - 2026

Advanced Coding Opportunities

A comprehensive resource to assist home-based medical care providers and practice staff with understanding the advanced coding opportunities beyond Evaluation and Management (E/M) Current Procedural Terminology (CPT®) codes that are available billing and reimbursement based on the high level of complexity of patient needs. These 2026 CPT codes align with the care provided and allow

Chronic Care Management (CCM) Care Plan Requirements - 2026

Chronic Care Management CCM Care Plan Requirements

This resource is intended for home-based primary care (HBPC) providers and practice staff and provides an overview of the 2025 required elements for the Chronic Care Management (CCM) Care Plan. This resource may be utilized as a guide to create a standard CCM Care Plan but is not all-inclusive. Refer to CMS guidelines for full

Advanced Primary Care Management (APCM) Toolkit - 2026

This toolkit equips home-based primary care teams with practical guidance for implementing Advanced Primary Care Management (APCM). Topics include starting an APCM practice, staff communication, technology solutions, safety protocols, telehealth integration, patient education, and Medicare FFS payment. It also features a patient script, FAQs, and helpful resources.

Advanced Primary Care Management (APCM) Care Plan Requirements - 2026

This resource is intended for home-based primary care (HBPC) providers and outlines the required elements of a comprehensive Advanced Primary Care Management (APCM) care plan. The APCM care plan enables care teams to align complex patient needs with coordinated, proactive management strategies and value-based care requirements. This guide reflects CMS expectations and best practices in

Annual Wellness Visit Template Guidelines - 2026

Annual Wellness Visit

This resource is intended for home-based primary care (HBPC) providers and practice staff and assists with the creation of a template for annual wellness visits (AWV) by providing the required documentation elements necessary to bill for this service; however, be sure to review the Centers for Medicare & Medicaid Services (CMS) guidelines for a full

Caregiver Burden in Home-Based Care: Assessment, Intervention, and Billing Essentials

This resource equips home-based primary care (HBPC) providers with practical, evidence-informed strategies to identify, assess, and mitigate caregiver burden. It provides validated tools, standardized workflows, community-based integration guidance, and billing essentials to support clinicians in promoting safer, more sustainable caregiving environments. Home-based care models significantly reduce emergency department utilization, unnecessary hospitalizations, and caregiver burnout through

HCCI and ILHCP Logo

The Illinois House Call Project - Cohort 1

The HCCI and Illinois House Call Project logos are designated for use by practices participating in the Illinois House Call Project. It may be included in promotional materials, presentations, websites, or other communications that highlight a practice’s involvement in the program. Use of the logo acknowledges participation and reinforces the connection to the broader Illinois

Advanced Primary Care Management (APCM) Care Plan Template - 2025

Empower your care team with a comprehensive, easy-to-use APCM Care Plan Template designed specifically for home-based primary care providers. This customizable tool streamlines patient care planning by integrating essential components of advanced primary care into one structured document.

Advanced Primary Care Management (APCM) Providers Checklist - 2025

CCM Providers Checklist

This resource is intended to assist home-based medical care providers with the implementation and delivery of Advanced Primary Care Management (APCM) services. It provides structured guidance to identify eligible patients, obtain required consent, initiate care appropriately, and fulfill service delivery and documentation standards as outlined in Centers for Medicare & Medicaid Services (CMS) billing requirements.

Innovation Award Promotion Guidelines

Elea Innovation Award

This resource document is designed to support recipients of the Innovation Award in promoting their participation in this unique learning opportunity. It includes key messaging, branding guidance, and outreach tips to help practices highlight their commitment to providing high-quality Chronic Care Management (CCM) services. By using this guide, practices can effectively communicate their role in

HCCI and ELEA Partner Logo

Elea Innovation Award

The HCCI and ELEA partner logo is designated for use by practices participating in the Innovation Award. It may be included in promotional materials, presentations, websites, or other communications that highlight a practice’s involvement in the program. Use of the logo acknowledges participation and reinforces the connection to the broader Innovation Award initiative. All usage

HCCI Brand Guidelines

This document serves as a comprehensive guide to ensure consistent and accurate use of the Home Centered Institute (HCCI) brand across all marketing, media, and communications efforts. It outlines key elements such as logo usage, color palette, typography, tone of voice, and other visual and messaging standards to help maintain a unified and professional brand

Wound Management for HBPC Providers – Wound Dressing Tips

Wound dressings should always be assessed when examining wounds. If the dressing is saturated, it may indicate that moisture is a concern. Wounds that are highly exudative require dressings with absorptive qualities consistent with the topical care plan. Most absorptive dressings are considered at capacity with ≥75% saturation. If the moisture is overwhelming while using

Suggested Equipment and Supplies for HBPC

Suggested Equipment and Supplies for HBPC

This resource list the recommended supplies that providers should carry each day in order to effectively perform procedures and provide quality care to patient each day.

Provider Orders and Instructions Form - 2024

Provider Orders and Instructions Form

The Provider Orders/Instructions Form is a comprehensive document designed to convey clear and precise healthcare directives from a physician to the patient and other healthcare professionals involved in the patient's care. This form serves as a written record of the physician's recommendations, treatment plans, and specific instructions to ensure accurate and consistent implementation across the

House Calls Medical History Form - 2024

House Calls Medical History Form - 2024

Semi-customizable & downloadable form used to gather important information about a patient’s past and current health status. This includes questions about the patient's medical history, including any illnesses or medical conditions, surgeries or hospitalizations, and medications they are currently taking. This comprehensive picture of a patient's health can help guide diagnosis and treatment decisions and

Patient and Provider Contract - Opioid Pain Medication - 2024

Patient and Provider Contract - Opioid Pain Medication

This contract serves as a vital document establishing a clear and comprehensive understanding between healthcare providers and patients regarding the responsible and appropriate use of opioid medications. This agreement is designed to ensure the safe and effective management of pain while minimizing the risks associated with opioid use.

Crossroads of Care: Managing Serious Illness in the Home (Session 4 of 4)

Crossroad of care logo

With the usage of value-based care models growing, the need for home-based primary and palliative care is on the rise. In many programs across the country, though, these two models have operated separately. There is, however, an increasing need for them to work more closely together to increase access to holistic, seamless care for patients

Crossroads of Care: Managing Serious Illness in the Home (Session 3 of 4)

Crossroad of care logo

With the usage of value-based care models growing, the need for home-based primary and palliative care is on the rise. In many programs across the country, though, these two models have operated separately. There is, however, an increasing need for them to work more closely together to increase access to holistic, seamless care for patients

Crossroads of Care: Managing Serious Illness in the Home (Session 2 of 4)

Crossroad of care logo

With the usage of value-based care models growing, the need for home-based primary and palliative care is on the rise. In many programs across the country, though, these two models have operated separately. There is, however, an increasing need for them to work more closely together to increase access to holistic, seamless care for patients

Crossroads of Care: Managing Serious Illness in the Home (Session 1 of 4)

Crossroad of care logo

With the usage of value-based care models growing, the need for home-based primary and palliative care is on the rise. In many programs across the country, though, these two models have operated separately. There is, however, an increasing need for them to work more closely together to increase access to holistic, seamless care for patients

COVID-19 and Home-Base Care-What Have We Learned

HCCIntelligence Webinar Recordings

The world has changed significantly since the onset of the COVID-19 pandemic, but what did we learn about Home-Based Care and its role going forward? Review this HCCIntelligence™ Webinar Recording from May 2021 to explore this interactive discussion.

Social Determinants of Health (SDoH) Screening and Coding Requirements - 2025

Social Determinants of Health

This resource is intended to provide home based medical care providers and practice staff an overview of the basic understanding of Social Determinants of Health (SDOH), its impact in patient care and medical decision making, and the importance of documentation in the SDOH Risk Assessment. All content reflects 2025 Centers for Medicare & Medicaid Services

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