Chronic Condition Management (CCM & PCM)

The Problem for facilities

A small group of residents with complex chronic conditions (like CHF, COPD, or diabetes) drives the majority of your hospitalizations, consumes most of your staff's time, and creates documentation headaches.

The iCare Solution

Our dedicated care coordinators, led by our clinical team, manage these residents through two distinct CMS programs: Chronic Care Management (CCM) for those with 2+ conditions and Principal Care Management (PCM) for those with one high-risk condition. We handle the care plans, monthly check-ins, and all billing documentation.

The Problem for clinics

A small subset of your primary care patients with multiple chronic conditions (like uncontrolled diabetes, hypertension, COPD, or depression) generates a disproportionate share of your workload. They require frequent touchpoints, urgent call-backs, medication adjustments, and care coordination—straining your staff, creating gaps in follow-up, and adding layers of documentation and billing complexity.

The iCare Solution

Our dedicated care coordinators—guided by our physician-led clinical team—support these patients through two targeted CMS programs: Chronic Care Management (CCM) for individuals with two or more chronic conditions, and Principal Care Management (PCM) for those with one high-risk condition. We create and update care plans, complete monthly touchpoints, ensure follow-through on care gaps, and manage all CMS-required documentation and billing. You stay focused on in-clinic care. We handle the ongoing coordination that keeps patients healthier and your practice running smoothly.

The Result

Better-managed residents, fewer hospitalizations, and a fully compliant, maximized revenue stream for the care you're already providing.