Doctor-led Chronic Care Management Maximizes

Vital Health Links' Chronic Care Management (CCM) provides high-touch care coordinated with your practice's workflows for the best possible outcomes for practices, practitioners, and their patients.

Doctor-owned and led, providing a culture of exceptional practitioner and patient support

Complete, turn-key services—no upfront investment or resources are required

Clinically-trained Care Coordinators use your workflows and evidence-based patient care

$0 RPM Devices

Full Clinician Support

  • Cost-free. Risk-free. Backed by full-service
  • doctor-led care management.
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Meaningful Chronic Care Management Improves Compliance & Outcomes

It takes more than disease management to affect patient participation in clinical outcomes: meaningful patient engagement is required. VHL’s clinical care management feels personalized to your patients. Coordinators are dedicated to your panels, adding consistency and familiarity, which leads to detecting and addressing social determinants, participation in education, and help with quality metrics.

Medicare: CCM is a Needed
Compliment to Face-to-Face Care

The Centers for Medicare and Medicaid Services (CMS) emphasizes that chronic patients' healthcare outcomes improve when care is virtually continuous—rather than mostly treated at the point of care, making chronic care management beyond the clinic's walls necessary and complementary. Vital Health Links' Coordinators manage all aspects of CCM as each practitioner would—applying the practitioner's evidence-based directives throughout care management personalized to the patient.

See Case Studies

2M billable minutes;
39,738:34:58 hours; 19.99 years

Practices like yours collected reimbursements from more than 2-million billable minutes last year. Each minute enhanced the value of chronic care management for patients and practitioners by applying clinical care through personalized engagement, maximizing practice revenue gains. Here's how it works:

Proven Patient Care Methodology


PRACTICE SUCCESS

Practices want to achieve their missions and grow their bottom-line

PATIENT SUCCESS

Practitioners want to impact improvement and empower patient success

TURN-KEY INTEGRATED CHRONIC CARE MANAGEMENT

Full-service solutions seamlessly operate with your systems and workflows

CCM PATIENT ONBOARDING PROGRAM

Includes welcome call, program explanation, identify patient concerns, the ideal time for a call, introduce care team, and identify immediate needs.

CONTINUOUS DEDICATED ENROLLMENT

A specialist manages qualified patients enrollment, including profile set-up.

COMPLETE PROGRAM IMPLEMENTATION

LIVE & DEDICATED TO YOUR PANELS

Clinically-trained Coordinators facilitate personally engaging patient education & compliance.

DIRECTED BY YOUR WORKFLOWS

Clinically-coordinated care managers follow workflows customized to practitioner directives & disease guidelines.

END OF MONTH BILLING

Generated with CPT & ICD10 codes

SHARED DECISION-MAKING

Leveraging patient rapport to bridge gaps in care, functional assessments, social-determinants risk assessments, quality metrics, education, and coaching.

ACTIVE SUPPORT NETWORK

Facilitate connections with community and healthcare organizations

REPORTING AND RESULTS COMMUNICATIONS

Full EMR utilization for notes, billing and messaging. We provide quarterly reports to enable transparent visualization of the

Improved Outcomes From from our CCM program

Increased Revenue
Improve Quality metrics
Increased Patient engagement
Improve staff utilization
Reduce Burnout

Maximizing Growth

$745.92

ANNUALLY/PER PATIENT

CPT CODE 99490
MONTHLY CCM SERVICES

$1,212.84

ANNUALLY/PER PATIENT

CPT CODE 99454 & 99457
MONTHLY RPM SERVICES

$1,011.48

ANNUALLY/PER PATIENT

CPT CODE G0511
MONTHLY CCM FOR FQHCS/RHCS

Keeping you Compliant

A comprehensive approach to CMS compliance keeps you in the business of changing healthcare outcomes without interruptions. Robust software created by physicians to cover every detail of CMS requirements and notes relevant to your patients’ care.

Center for Medicare and Medicaid Services
CPT Code Compliance

A physician or other qualified healthcare professional. Physicians and some non-physician practitioners: certified nurse-midwives; clinical nurse specialists, nurse practitioners; and physician assistants may bill for chronic care management services. Specialty practitioners may provide and bill for CCM.

target="_blank">Furnishing Profitable CCM

Recording Patient Health Information
and Payment

Advanced consent for chronic care management services is needed. It helps ensure the patient is engaged in applicable cost-sharing, after which ongoing structured recording of a patient's demographics, problems, medications, and medication allergies are necessary using certified Electronic Health Record (EHR) technology. Payment information by geographic location by code is accessible through the Medicare PFS Look-Up Tool. Learn More>

MIPS and MACRA

Vital Health Links' CCM helps practitioners provide high-value patient care—at scale—rewarded through the Merit-based Incentive Payment System (MIPS) and the Medicare Access and CHIP Reauthorization Act (MACRA). Learn More>

Chronic Care Management and HIPAA Safety

VHL is compatible with HIPAA via a patient web portal and through the use of certified Electronic Health Records and EMR/EHR network integration. See Here

CCM and Covid-19

Since the COVID-19 national health crisis began, Vital Health Links’ Chronic Care Management has proven to help providers with the flexibility to give meaningful clinical support for acute and chronic illness treatment and dependable revenue recovery. Read how Vital Health Links chronic disease management prevented a clinic from laying off workers while other clinics closed and maintained 90% enrollment retention.

CCM and Healthcare Hiring Shortages

Increases in the elderly population and chronic diseases create even more demand for clinic staff, leaving them overworked and burnt out. In addition, few new nurses are entering the profession to compensate. Clinically-trained VHL Care Coordinators help bridge gaps amidst system-wide shortages, complimenting a practitioners’ care at scale with guidelines-driven, personalized care.

Hassle-Free Assessment

We understand that chronic care management is a significant step for your practice. However, as doctors, we are here to help you assess the impact CCM could have on your systems rather than sell you a product. Because to us, clinically-led patient care is personal.