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Chronic Care Management Group Partnership.

Our value-based partnership with Chronic Care Management Group (CCMG) allows NeuroCare Specialty Home Care the ability to focus on clients at the highest risk of readmission.


7 of the top 10 causes of death in 2018 were due to chronic diseases! The elderly are more likely to have chronic conditions with over 2/3 of all Medicare beneficiaries having 2+ chronic conditions. In fact, 93% of Medicare dollars spent are on patients with 2 or more chronic conditions. These chronically ill patients have the highest hospitalization rate, the highest readmissions rate, and are the highest utilizers of home health services.

As the number of chronic conditions that a patient acquires, increases, so does the number of specialists and other providers treating these patients. In fact, 55% of chronically ill patients see 3+ physicians with 11% seeing over 6+ physicians annually.

Coordinating efforts between various members of the care teams becomes a challenge; poor handoffs can result in redundancy in medications, unclear instructions, fragmented data, and general confusion.


Care coordination or facilitating the patient’s care activities between encounters (such as office visits) is a critical part of managing complex handoffs that occur while delivering care for chronically ill patients.

In 2015, the center for Medicare and Medicaid services (CMS) created a new program utilizing care coordination to help improve outcomes and reduce costs for chronically ill patients. This program is called, “The Medicare Chronic Care Management Program (CCM),” and reimburses providers in the absence of a personal, face-to-face office visit.

Medicare pays a monthly amount, per patient, for the preventative program. This amount is paid directly to the preventative care management team and is totally separate from the care and financial renumeration to the primary care provider.

CCM is a critical component of primary care that contributes to better outcomes and higher satisfaction for patients. CCM care is totally separate from the care administered by the primary care provider, and is billed separately from the primary’s practice, with totally separate CPT codes. CCM works in partnership with the primary care provider and provides help between the patient’s previous office visit and the upcoming visit.

Who is eligible for the Medicare Chronic Care Management program?

Patients with “Original Medicare” coverage (Medicare A & B, Medicare + supplemental insurance, Medicare/ Medicaid)

Patients with a minimum of 2 chronic conditions, for example:

The preventative team is responsible for maintaining accurate data, collecting records, and informing the primary medical provider (PMP) of any and all data collected. The preventative team is also responsible for reporting to the PMP in a timely manner with absolute accuracy and privacy.

All patients that elect to participate in the CCM preventative program are required to be initially examined and evaluated by the preventative team physician who subsequently reviews all health records and creates a problem list. All future preventative measures and plans are derived from the problem list.

Our clinical staff includes physicians well adept in-patient care management and RN’s skilled in patient care and knowledgeable in rules and regulations related to senior care facilities. In addition, we have RN’s certified in nutrition and diet care, life coaching, and holistic medicine.

Our staff also includes a podiatrist, a psychiatrist specifically trained in senior depression and PTSD, a physical therapist, massage therapists, and certified physical exercise trainers who are trained in senior care exercise. Our administrative staff is experienced in electronic health records (EHR) management, data collection, and billing.

We specifically utilize the software services of Care Harmony, a company that specializes in chronic care management solutions designed to offer healthcare providers an easy limited-risk management of chronic care conditions.

Brownell H. Payne, MD

Medical Director/CEO

Chronic Senior Care, Chronic Care Management Group