COVID-19 Info and Tele-Nursing Triage Protocols

As the corona virus (COVID-19) affects practices nationwide, Circlelink’s tele-nursing team (100% Registered Nurses) is here to help with the worried well and sick at home.

Our RNs triage Chronic Care Management (CCM) patients, or others, answering questions and referring them to appropriate care settings before patients physically visit practices or take up staff time with calls.

After ~5 years working with patients most at-risk for COVID-19 (Medicare patients with multiple conditions), we assembled the following COVID-19 exposure protocol and content base, shared with our healthcare provider customers on 3/12.

We partnered with ClearTriage for their gold standard Schmitt-Thompson protocols and evidence-based content, including below COVID-19 exposure protocol.

Hopefully, below will help any practices and healthcare providers dealing with potential COVID-19 patients. Our team is humbled to work with these healthcare providers/heroes.

If you think CircleLink’s tele-nurses or platform can be helpful, please reach out to

COVID-19 Exposure Protocol

A Summary of Preventive and Protective Measures Specific to Our Patients

  • Medications, medical supplies adequately filled
  • Respiratory and hand hygiene
  • Practice social distancing, crowd avoidance, avoid non-essential travel
  • Stay home as much as possible

People at Risk for Serious Illness from COVID-19

Patient education materials

Print resources


Information for Travelers


Healthcare Professionals: Frequently Asked Questions and Answers

Pertinent Guidelines for Patients at Home

How COVID-19 Spreads: International Areas with Sustained (Ongoing) Transmission

Preventing the Spread of Coronavirus Disease 2019 in Homes and Residential Communities

Evaluating and Testing Persons for Coronavirus Disease 2019 (COVID-19)

Interim Guidance for Discontinuation of In-Home Isolation for Patients with COVID-19

Interim Guidance for Implementing Home Care of People Not Requiring Hospitalization for Coronavirus Disease 2019 (COVID-19)

Latest from CDC:

What’s New

Common Challenges when Practices Implement CCM Programs


APPROVED: New Care Management/RPM/CCM Codes for 2020

In October, we posted about Medicare’s proposals for drastic improvements to Chronic Care Management (CCM) and other reimbursable programs like Remote Physiologic Monitoring (RPM), starting Jan. 2020.

Good news: These changes were just finalized with the release of Medicare’s 2020 Physician Fee Schedule.

Below, we explore the most impactful changes that practice leaders need to know.

Table of Contents:

1. Transitional Care Management (TCM)
a. Fee increase
b. Now allows other care management to be concurrently billed with TCM

2. CCM
a. New code for each additional 20 minutes of care management beyond 20 minutes per month
b. Complex CCM removes requirement for ‘substantial care plan revision’

3. Remote Physiologic Monitoring (RPM)
a. New code for each additional 20 minutes of care management beyond 20 minutes per month
b. Allows off-site care managers

4. New “Principal Care Management” (PCM) codes for patients with 1 ‘serious chronic condition’


1. TCM (Transitional Care Management) fee increase

As discussed in our last post, Medicare found that i) TCM utilization is still low compared to the number of Medicare discharges and that ii) TCM services reduced readmission rates, lowered mortality, and decreased health care costs.

To increase clinicians’ use of this valuable care program, Medicare is increasing reimbursements for TCM codes by as much as 12% and allowing care management codes like CCM (ex: CPT99490) to be concurrently billed with TCM: “we are finalizing… to allow concurrent billing of the care management codes currently restricted from being billed with TCM. This includes allowing concurrent billing of TCM with the 14 codes specified in Table 20, as well as CPT codes 99490 and 99491” (page 397)

2. Chronic Care Management (CCM)

Medicare again referenced data showing cost savings from CCM and reiterated their intention to responsibly expand CCM to appropriate patients. The two key proposals discussed in our last post were implemented. That is, additional care management time beyond 20 minutes can be reimbursed, and, Complex CCM no longer requires a significant care plan change. However, some minor coding changes were made in the final ruling:

a. The finalized code for each additional 20 minutes of care, G2058, will take the place of the proposed code “GCCC2”, and be billable on top of CPT 99490

  • Reimburses “each additional 20 minutes” of needed non-face-to-face follow-up care beyond the first 20 minutes per month.
  • 0.54 RVU
  • G2058 can be billed concurrent to 99490, up to 2 times for the same patient per month
  • Medicare: “we are finalizing GCCC2 (the add-on for non-complex CCM clinical staff time), henceforth referred to as G2058, because this code addresses what we believe is an important gap in the current code set” (page 404)

b. Complex CCM codes no longer require “substantial care plan revision”. This requirement limited care for many folks requiring 60+ minutes of care coordination where there may not be a ‘substantial care plan revision’ as defined by CMS. To prevent overuse, Medicare is keeping the “moderate or complex medical decision making” requirement in place.

3.  Remote Physiologic Monitoring (RPM) has a new 20 minute code and allows remote care managers

Medicare finalized the 2 key changes for Remote Physiologic Monitoring (a set of ~$60-$120 reimbursements, per patient per month, for monitoring+managing vitals like blood sugar/pressure).

First, Medicare finalized a new add-on code, CPT 99458, which pays 0.61 RVUs for an additional 20 minutes of clinical care management time relating to vitals monitoring. This 99458 code is in addition to the existing CPT 99457 code for the first 20 minutes.

Second, Medicare now allows general supervision for the CPT 99457 and 99458 codes, meaning remote care teams may provide this care. Specifically, they ”designate both CPT code 99457 and CPT code 99458 [to be] care management codes as defined in § 410.26(b)(5) of our regulations.” (page 431) This means that off-site care managers like CircleLink’s 100% RNs can provide the “Remote physiologic monitoring treatment management services”, whereas in 2019 the clinical staff providing services needs to be on-site in the same facility as the supervising provider/doctor.

4. New “Principal Care Management” for patients with 1 ‘serious chronic condition’

Medicare finalized 2 codes (below) relating to “Principal Care Management” to cover patients with a single serious chronic condition. This enables care management for patients who don’t qualify for CCM’s 2-condition requirement.

  • G2064 (1.45 RVUs for 30 mins of Dr. time)
  • G2065 (0.61 RVUs for 30 mins of clinical staff time)

However, it should be noted that G2065 requires 30 minutes of staff time while paying the same RVU as CCM pays for 20 minutes.

These codes require 1 condition for which a patient has received care for 3-12 months, which puts patient at risk for hospitalization, or has resulted in a recent hospitalization.

While a practitioner (Primary Care or Specialist) may bill PCM concurrent with RPM, they may not bill PCM with other care management codes (e.g., CCM) for the same patient/month.

Finally, while PCM’s requirements mirror CCM’s, there are two key differences:

  • Care Plan: PCM requires a “disease-specific” care plan vs. CCM’s comprehensive care plan
  • Documentation: PCM requires that communication/care coordination “between all practitioners furnishing care to the beneficiary… be documented by the practitioner billing for PCM in the patient’s medical record.” (page 420)

Is your practice prepared to take advantage of these adjustments to CCM, RPM and other care management programs? CircleLink demystifies the reimbursement process and can assess if your practice is a fit for increasing revenue/patient health.

To learn more, please drop us a line at or call 917-999-6560.


NOTE:  FQHCs/RHCs may not bill for the new CCM and RPM codes. However, patients meeting PCM requirements are billable under the G0511 FQHC/RHC care management code.

Dr. Survey: What’s stopping Chronic Care Management and other programs


In 2015, Medicare launched Chronic Care Management (CCM), a program incentivizing practices to follow up with chronic condition patients outside the office between visits. Other programs followed to improve health, like Behavioral Health Integration (BHI), which focuses on follow-up between visits for patients with mental conditions. These programs provide a significant financial incentives to providers, up to ~$42-$80 per  patient per month, or up to $200K+ per provider annually. 

However, despite these programs’ health improvements and systemic cost savings, many doctors and their staff lack the infrastructure and extra staff to implement them.

CircleLink Health conducted a survey of 51 primary care providers and 9 cardiologists to determine their general level of CCM awareness and preparedness. The results suggest that while physicians believe their practices could benefit from CCM/BHI, they struggle to implement these programs effectively. In fact, despite 77% of physicians polled being aware of Chronic Care Management’s launch in 2015, only 12% reported they are billing for CCM consistently.

The Challenges of Treating Patients with Chronic Conditions:

Patients with chronic illnesses can be time-consuming for practices. For instance, follow-up calls that can ensure these patients take their medication and understand their doctors’ instructions take hours per week. Specifically, our poll showed most doctors’ staff spending between 8-20 hours per week on such follow-ups. (62% reported their staff spent 8+ hours each week on such calls.)

Medicare Chronic Condition Chart

Even with the above time being spent on follow-ups, only 7% of physicians polled reported their staff always having more than enough time to call their chronic condition patients in between appointments. 

Which makes sense: Office staff are crucial to the day-to-day operations of practices. Spending hours on the phone with these chronic conditions patients can disrupt their workflow. Having new resources funded by CCM or other preventative programs can free up staff to focus on patients who need attention in-office, among other priorities.

The Challenges of Implementing CCM Programs:

Although preventative care programs like CCM seem to be a perfect solution to these challenges, our survey found that physicians struggle with finding the needed staff time, resources and infrastructure.

Per the below chart, the three most cited barriers are (among the 65% of respondents who hadn’t launched):

  • Lack of staff time required for new revenue programs
  • Difficulty in understanding complex program requirements
  • Unfamiliarity with these programs’ reimbursements

Barriers to implementing Medicare preventative health programs chart

In addition, finding time to research how to implement a CCM program can be difficult for physicians and staff who fill their entire workdays with clinical matters. The complex regulatory environment and resulting operational needs surrounding these programs/reimbursements makes this work time consuming. 

CircleLink Health Can Help Your Practice Implement a CCM/BHI Program:

Luckily, CircleLink Health provides the technology, telephone RNs and guidance physicians need to implement successful preventive care programs with zero additional staff or upfront costs. From full-service CCM/BHI solutions to customized/targeted offerings based on practices’ needs, CircleLink can help. Interested in learning more? Send an email to

Are Your Care Coaches Earning Patient Trust Over the Phone? (Why and How-to)

Telehealth is an area of growing importance in healthcare as it enables convenient patient care and follow-up at lower costs than the status quo health facility, especially for patients who live in rural areas or need follow-up between visits to manage chronic conditions. In these cases, receiving care over the phone from a qualified professional can be enormously beneficial. 

CircleLink is part of this change, with best-in-class tele-nurses who serve thousands of patients with chronic or behavioral issues each month. The work that these registered nurses do to support patients between doctors’ visits significantly improves revenues, and has been shown to reduce costs through better health outcomes

However, there is a challenge for telehealth.  Patients don’t have the same face-to-face contact with healthcare professionals. Apart from prescribed treatments, the psychological support received from direct interactions with healthcare professionals is a powerful force in fostering speedy recovery and peace of mind among patients. Conveying this psychological support over the phone, however, is more difficult than doing so in person. The key to making remote care effective is for healthcare professionals to earn the trust of these patients whom they may never meet.

Why trust matters

Building trust in a telehealth relationship is important for three reasons: First, for clinics and hospitals, trust is key to retention in chronic care management or behavioral health integration programs. Adherence has been shown to be 2.5 times higher in patients who have high levels of trust in their doctor than in those with low levels of trust (adherence rates of 43.1% and 17.5% respectively). Patients who adhere are more likely to stay with the program, meaning better revenue for the clinic or hospital.

Second, trust leads to better healthcare outcomes for the patients. The patient-clinician relationship has been shown to affect health outcomes that are both objective (such as blood pressure) and subjective (such as pain scores). A trusting relationship is not only important for making the patient feel good, but also for their physical well-being and recovery.

Finally, patients are more likely to stick with their clinician when they receive consistently outstanding service.  Feedback from CircleLink’s registered nurses illustrates this relationship vividly: 

“I spoke with our patient today, and she was very grateful for our program, says that she got a call from his [practice] office [after Circlelink RN coordinated], an appointment was set up and she is feeling much better. Says she never would have gotten in so quickly without our [CircleLink’s] call.” – Suzanne, registered nurse. 

“The patient was very happy because after 1 1/2 weeks of trying to get a script for a glucose meter, after my call to her they resolved it within a few hours [due to CircleLink RN following up with practice]. She was also appreciative of my follow up call.” – Lisa, registered nurse.

How to build trust: The Basics

Building trust requires investing in time and practice, but it’s well worthwhile. We at CircleLink have found techniques that enable new tele-nurses to adapt their existing expertise and patient experience to telephone care quickly. We’re delighted to share some of those insights below.

Right at the start of a call, it is important for the tele-nurse to introduce themselves and mention that they are calling on behalf of the patient’s specific doctor straight away. They may also mention the name of the patient’s practice. This will let the patient know that they can trust the caller, and, will make them feel more at ease. 

Next, the caller should explain that the patient’s doctor endorses the chronic care management program, and that the call was set up by the doctor in order to keep in touch between appointments. This helps the patient understand the relationship between the telehealth services on offer and the physician’s regimen that they are already familiar with. 

Once it has been established that their trusted doctor supports the patient using the telehealth service, a more in-depth conversation can begin. In the experience of our nurses, discussing medication is a productive first step, as it builds credibility with the patient. For example, the patient may wish to discuss how to manage their medication regimen, or to list any side effects they might be experiencing. By focusing conversation on these important details, it demonstrates that the telehealth nurse is a trained medical profession who understands the patient’s specific care needs.

Finally, taking the time to listen to the patient cannot be stressed enough in trust building. In our experience, allowing some silence into the conversation invites the patient to ask questions or to bring up issues that are concerning them. This is important in making the patient feel comfortable sharing more key health and lifestyle information, and to having them involved in their care. 

More Advanced Tips from CircleLink’s Tele-nurses

In addition to these basic trust-building techniques, CircleLink’s qualified tele-nurses have their own tips to share on building trust:

“First and foremost, smile and be enthusiastic about the program, the practice and the patient. You can hear a smile over the phone,” says Lisa B. RN “Get personal, and make reminders in your notes so you can refer back to spouses and names of family they live with, pets’ names, etc.” 

LeAnna, another registered nurse at CircleLink, likes to ask open ended questions like “How have you been feeling?” or “What is new with you since we spoke last?” in order to give patients space to open up that isn’t dictated by a script. She also emphasizes the importance of learning the patient’s preferred name and their preferred times to speak on the phone for their convenience.

Both LeAnna and Lisa stress the importance of being reliable and showing up to phone appointments as promised. In addition, it helps to remember that elderly people can be wary of phone scams, so LeAnna encourages the patient to call the doctor’s office and confirm her identity if they feel unsure. “I’ve found that when I do that, the next call with the patient goes extremely well, and they are appreciative of our understanding their need to get that reassurance that we are who we say we are,” she explains.

The nurses’ experiences confirm what the research has shown too: that making the patient feel heard is vital. “Listening to the patient and validating that they are being heard is important,” says LeAnna. “I want every patient to know that they have my full attention, and I care about what they are saying.”

In conclusion

Building trust with patients is key to successful telehealth programs. Both the scientific evidence and our nurses’ clinical experience backs this up. For more information about telehealth and how it can benefit both health providers and patients, requests a 1-on-1 free consultation here.

What’s My Reimbursement and Profits for CCM?

A chronic care management (CCM) or behavioral health integration (BHI) program has great potential benefits for patients, but requires considerable investment of resources and administration across a large number of staff. These hurdles have contributed to the 2-3% adoption rate of CCM in the 1st two years of the program*. On the BHI side, a brief from the Institute for Clinical and Economic Review (ICER) showed that BHI is more effective at promoting improved health outcomes than traditional care, but costs between $20 to $3,900 per patient depending on location and individual patient needs.

The good news is that the extra revenue that a practice receives from BHI/CCM programs, which is roughly $40-80 per patient per month, can offer significant profits and ROI, if managed properly. This is where the benefit of prior CCM/BHI experience comes in.

There’s also additional program value in terms of health, quality of life and savings to Medicare.  For example, a report by Mathematica from 2017 found that CCM services (for the sample studied vs. a control group) reduced net Medicare costs by over $30M.

So if it makes sense for your institution to offer a CCM / BHI program, should you run it yourself, or should it be outsourced? Today we’ll help you make this decision by walking you through the reimbursement and profitability of CCM and BHI programs.

Data on reimbursements

The reimbursement for CCM varies considerably between states, ranging from $39 to $57 per patient per month. The feasibility of administering a cost-effective CCM / BHI program therefore changes depending on the cost, effectiveness and efficiency of overheads. Wondering what your reimbursement is?  Drop us a line at for access to our comprehensive region by region reimbursement data set.


Profitability drivers and example calculation

1. Staffing

Firstly (and most importantly, given high staffing costs associated with care) is the fixed overhead costs or vendor costs for staffing relative to the rate of reimbursement. CCM/BHI requires co-ordination and management of a team, including roles such as primary care physician and care manager.

When considering staffing costs, also take into account all of the staffing hours that are required on top of the 20-40+ minutes per patient per month of direct patient contact. This includes time for issues like determining patient eligibility, enrolling patients (and documenting enrollment), preparing care plans, tracking approval of those plans by a doctor, and presenting care plans to patients. There will also be considerable time for non-call time activities like scheduling calls, documenting calls, managing/training care coaches, and trying to contact unresponsive patients. Finally, there are also time costs in determining which patients can be billed for and preparing their billing information, as well as the usual staffing costs of vacation and sick days.

In terms of BHI programs specifically, behavioral health specialists are an important group to consider, as they may need to be hired from outside the usual streams of staff acquisition. Depending on patient needs, behavioral health specialists could come from a range of backgrounds with different associated levels of cost including social work, nursing, psychiatry, psychology, substance abuse support, or counseling. As with other programs, the costs for staffing will vary depending on region, and also on whether these staff are permanently employed or are agency workers.

2. Number of patients enrolled and their duration on program

A second key consideration in terms of profitability is the reimbursement, driven by i) duration of the program for each patient, ii) the number of patients enrolled and iii) the number of enrolled patients reached each month. As mentioned in the introduction, a CCM/BHI program can be expensive to set up without outside help. To offset this initial expense and the ongoing fixed costs of an in-house program, practices must soberly estimate if they have the HR and technology to efficiently execute on each of parts i), ii) and iii) above.

A typical CCM patient, as described in the Mathematica report, receives services for between four and ten months. In the case of practices using CircleLink to avoid such fixed cost risk, patients are typically on the CCM/BHI program for somewhere in the range of eight to twelve months and 90% of active, reachable patients may be billed each month, as they are given care by high level staff like registered nurses. CircleLink has found that using higher level registered nurses keeps patients on the program longer, vs. using medical assistants.

3. Total profitability

The total profitability of the program can be calculated relatively simply: consider the patient-months billed times the reimbursement rate, then subtract total costs such as staffing costs, employment taxes, real estate and facility management costs, and the overhead costs of the team doing care coaching.

For example, consider a Licensed Practical Nurse working on a CCM program operating in New York. The staffing costs of such a position are around $58,000 per year, or around $70,000 in total including overhead costs and taxes. With a NYC reimbursement rate of $49 per month, as shown in our reimbursement table, you can see that the nurse in question would need for bill for 120 patients per month just to break even.

When you consider all of the staff work required in addition to the care coaching call time, plus the LPN being pulled into non-coaching facility duties, this level of billing may not be feasible. Achieving a higher level of patient billing for a return on investment may be even further afield.

CircleLink can help

If you are looking for support in the management of your own CCM / BHI program, then CircleLink can help. Our services have zero upfront costs, can launch in 2-4 weeks and are always profitable (you only pay fees for billable patients). Care coaching is handled by our team of 100% registered nurses so you needn’t worry about hiring, training, or scheduling staff to follow up with patients between visits. And we offer a dedicated expert account manager to walk you through the process and answer any questions. Our service is trusted by both large health system practices and smaller clinics nationwide. Call us today at 917-999-6560 to request a demonstration and learn how we can help you offer the best care to your patients.

*for 2015-2016, according to CMS’s 2017 Physician Fee Schedule and assuming ~70% of Medicare beneficiaries have the 2+ chronic conditions needed for eligibility

Interview with care coach LeAnna R., RN


Care Coaches are the key to Medicare’s Chronic Care Management (CCM) and Behavioral Health Integration programs, providing the non-face-to-face follow-ups and coaching to manage chronic/mental conditions when they matter, between regular office visits.  At CircleLink, we use 100% RNs with over 10 years of experience and focus on providing a best-in-class experience to these key partners. Care coaches are the true stars of CircleLink’s platform.

In that vein, today we’re showcasing what it’s like to be a CCM Care Coach in the words of one of our top care coach partners, LeAnna R., RN.

A day in the life of a CCM nurse

I have to start by telling you that a day spent on the job as an RN Care Coach is wonderful. Switching to this job has been a rewarding and welcome change for my family and myself. I don’t have to commute or travel every day; I don’t even have to go outside if the weather’s bad. I can stay home with my family and cats, one of whom is 16 years old and needs me home throughout the day.

One of the best things about this job is flexibility. I have a set amount of hours that I work each day. Once I’m ready to start my work day, I log in and let my Director of Operations and Community Manager know I’m ready.

The first thing I do is check my callback tracker to see if any patients called while I was away. I start by calling those patients first. Following that I start on my scheduled activities calling whoever’s most appropriate first based on my patient’s preferred call times.

The calls themselves are diverse and include people from all lifestyles. Some patients live alone, love to talk, and look forward to their call each month. I come to know not only their health concerns, but also about their family, pets, financial struggles, and community concerns. Other patients are busy and don’t have much to say when I call. However, they still appreciate knowing they’ll be checked in on each month and that we’re here if they need something.

After talking to the patient and making recommendations based on their care plan and current health, I note the patient’s progress and I forward that note and/or call the practice, if necessary. Once finished with the patient’s progress note I schedule his or her next call and proceed to call another patient.

I keep working until I run out of calls or finish my list, whichever comes first. I then message my Director of Operations and check out for the day. 

How I became a care coach 

I started my nursing career as a Registered Nurse in 2008, working in the ICU. That was an incredible learning experience that helped me become the nurse I am today.

Specifically, it helped foster my passion for teaching patients about lifestyle choices that can help them. I realized that many of our ICU patients’ problems were preventable by better life decisions, and I wanted to make a difference in that area.

After leaving the ICU I worked in Telemetry for a few months and saw many of the same issues there too. This eventually led me towards a nursing job in the Wellness and Preventative Medicine industry. In this position, I traveled to organizations and corporations to provide onsite wellness screenings and vaccinations for employees.

Doing this for a few years, I was able to see patients making lifestyle changes because of the results and coaching they got from our screenings. The excitement they had when telling me about the weight they had lost, the change in how they felt, and their lower risk for health complications was incredibly rewarding.

While I loved my work in the Wellness industry, I was tired of traveling and began looking for other options that would have me home more. That’s how I ended up at CircleLink Health.

To date, this has been my favorite job. It lets me use my nursing knowledge, communication skills, and love of helping people — all without having to leave the comfort of my home.

A particularly memorable case 

One time, I was making a first-time call to a patient. When she answered, she was out of breath and sounded very scared. She couldn’t catch her breath and hadn’t dialed 911 for assistance, so I called emergency services on her behalf.

While we were waiting for them to arrive, I talked to my patient and helped her stay calm. When I called her the next month, she was very appreciative and said she didn’t know what would have happened if I hadn’t called her that day.

Most positive impact on patient health 

I was once on call with a male patient and asked if he had any health concerns. As he was describing his symptoms, I got an eerie feeling that all of them were consistent with Congestive Heart Failure.

Although the patient felt seeing his doctor would be a bother, since the last check-up had happened just 2 months prior, I ended up calling his doctor’s office and speaking with a nurse. We were able to collaborate to get the patient to the office within an hour, and evaluated him before transferring him to a hospital for CHF treatment.

The patient’s spouse later said she was scared to think about what would have happened if I hadn’t called them that day and she expressed gratitude for the service.

With new medication and a better understanding of the patient’s dietary restrictions, they were able to improve his condition. That was very rewarding for me.

Most challenging practice

The most challenging practice is one that isn’t making full use of our service. For example, a practice that only wants to receive notes from nurses in emergencies is, in my opinion, missing out on many of the benefits of the CCM program. Also if the practice does not allow me as an RN Care Coach the ability to speak with or leave a message with the provider’s nurse this presents a challenge as well.

Biggest remote care coaching challenge

My biggest challenge would have to be getting patients to understand the service we provide and trust what I do and who I am. Getting the program details across isn’t always easy, but I have noticed that two things help.

First, I encourage patients to ask questions and I provide them simple, precise answers. Second, practices that proactively notify patients about what’s going to happen beforehand can help a great deal.

Sometimes, patients are very skeptical and do not want to speak with me regarding any of their information until they have spoken with their provider. I welcome this concern and encourage patients to verify the information I provide before we proceed with further calls. I have found that by acknowledging patient’s feelings and allowing them the chance to have their concerns addressed a solid foundation for a trusting nurse/patient relationship is developed.

– LeAnna R., RN

If you’d like to learn more about CCM or see how we can help, great! We’re here for you. Please email or call (917) 746-2708.







Chronic Care Management (CCM) Reduces Hospitalization According to Healthcare Executives

The United States is notorious for poor health outcomes (among lowest in western world) despite the highest per capita health spending globally.  One large area for improvement is chronic condition care which comprise 86% of healthcare spending, and a significant portion is preventable, according to the Centers for Disease Control and Prevention.

Medicare’s new Chronic Care Management (CCM) program answers the call and aims to improve outcomes while reducing costs and hospitalizations for patients with conditions like Diabetes and Asthma. Participating providers earn additional reimbursements for engaging patients with 2+ chronic conditions between regular practice visits.

And there’s good news: A recent survey by the Healthcare Intelligence Network (HIN) indicates that 2/3rds of healthcare executives observed reduced hospital admissions which they attributed to their CCM programs (N = 100 healthcare companies).

Prior studies examined outcomes for similar chronic disease follow-up protocols, but not CCM specifically. These studies also confirmed reduced costs and improved health. For example, Medicare and Pepsi/Rand studied the effects of chronic care coaching + education programs similar to CCM. They found ~$130 of cost savings per patient per month along with reductions in hospital admissions ranging from 17% to 29%. (Source: CMS 10-year study pg 18 / PDF pg 29 & Pepsi/Rand 7-year Study)

If you’re interested in learning more about CCM and other reimbursements for improving patient health, contact us at or (917) 999-6560! We offer comprehensive programs with zero up-front costs or commitments.

CircleLink Team

CircleLink Featured by HIPAA Security Expert MedStack

CircleLink is delighted to have been profiled by MedStack, a HIPAA-compliant hosting company and security expert.

Read the profile and interview with our CEO here.

You can learn more about MedStack here.

Thank you MedStack!
CircleLink Team