CCM Service
Chronic Care Management for Skilled Nursing Facilities
Gabby Health helps facilities deliver structured chronic care coordination for residents with multiple long-term conditions while generating new Medicare revenue.
Book a Demo
Delivering Measurable Results
30%+ Reduction in Hospital Readmissions
Proactive monitoring and care coordination help detect deterioration earlier and prevent avoidable hospital transfers.
25% Improvement in Chronic Condition Management
Structured care plans and monthly patient outreach improve long-term disease stability for residents with complex conditions.
40% More Efficient Care Coordination
Structured care plans and monthly patient outreach improve long-term disease stability for residents with complex conditions.
25% Improvement in Chronic Condition Management
Structured care plans and monthly patient outreach improve long-term disease stability for residents with complex conditions.
Gabby Health CCM Services
Seamless Patient Onboarding
Quickly onboard patients from consultation to your CCM program with one guided flow — from eligibility screening and enrollment to care plan setup. Gabby Health removes the friction from onboarding so your team can enroll more patients with less administrative effort.
- Smooth EHR Integration
- One-Click Patient Chart Creation
- Guided Patient Assessment
- Automated CCM Eligibility Checks
- Digital Consent Management
Personalized Care Planning
Build individualized care plans that reflect each patient’s unique chronic conditions, goals, and risk factors. Gabby Health’s platform uses clinical data and assessment results to generate tailored care plans — ensuring every resident receives targeted, condition-specific coordination from day one.
- AI-Assisted Care Plan Generation Based on Patient Data
- Condition-Specific Templates for Common Chronic Diseases
- Patient Goal Setting and Milestone Tracking
- Automatic Care Plan Updates Based on Clinical Changes
Patient Management
Manage your entire CCM patient population from a single, centralized view. Gabby Health gives care coordinators full visibility into every enrolled patient — their status, upcoming actions, overdue tasks, and risk levels — so nothing falls through the cracks across your caseload.
- Centralized Patient Roster with Status Indicators
- Task Management and Overdue Action Alerts
- Risk-Level Sorting and Priority Filtering
- Care Coordinator Assignment and Workload Balancing
Customized Dashboard
See what matters most at a glance. Gabby Health’s customizable dashboards let clinical leaders and care coordinators configure their view around the metrics, alerts, and patient segments that drive their daily decisions — from program enrollment trends to outcome tracking.
- Configurable Widgets for Key CCM Metrics
- Program Enrollment and Compliance Tracking at a Glance
- Role-Based Views for Coordinators, Nurses, and Administrators
- Real-Time Alerts and Notifications on Dashboard
Real-Time Vital Tracking
Quickly onboard patients from consultation to your CCM program with one guided flow— from eligibility and enrollment to care plan setup.
- Smooth EHR Integration
- One-Click Patient Chart Creation
- Guided Patient Assessment
- Automated CCM Eligibility Checks
- Digital Consent Management
Proactive Patient Engagement
Stay connected with patients between visits through automated, personalized outreach. Gabby Health drives consistent patient engagement with scheduled check-ins, health reminders, and educational content — keeping patients involved in their own care and improving long-term chronic condition management.
- Automated Monthly Patient Outreach and Check-Ins
- Personalized Health Education Based on Conditions
- Medication and Appointment Reminders
- Two-Way Communication Between Patients and Care Teams
Automated Billing & Reimbursement
Turn care coordination into captured revenue — automatically. Gabby Health tracks all qualifying CCM activities in real time, calculates billable minutes, and generates submission-ready billing reports so your facility captures every dollar it’s earned without manual time logs or guesswork.
- Automatic Time Tracking Across All CCM Activities
- Real-Time Billable Minutes Counter with Threshold Alerts
- Monthly Billing Summary Reports Ready for Submission
- Support for Regular CCM and Complex CCM Billing
Why they trust Gabby Health
Gabby Health has completely transformed the way we monitor and manage resident care. The AI-powered insights help our team detect changes in patient conditions earlier, allowing us to intervene quickly and provide better outcomes for our residents.
Before using Gabby Health, reviewing patient records and making admission decisions was time-consuming. Now, our team can instantly access medical histories and care insights in seconds. It has significantly improved both efficiency and decision-making.
Gabby Health gives our care teams real-time visibility into resident health data. The platform’s AI recommendations help us prioritize patients who need immediate attention, ensuring that no critical changes are missed.
What I appreciate most about Gabby Health is how seamlessly it integrates with our workflow. Instead of searching through multiple systems, we can retrieve patient information instantly through the AI interface.
The dashboard is incredibly intuitive. With Gabby Health, our nursing staff can quickly access medication updates, patient history, and care notes, helping us stay proactive in delivering high-quality care.
Gabby Health has made accessing patient information faster and more reliable for our entire team. The AI assistant helps clinicians quickly find relevant medical details without navigating multiple systems.
Gabby Health has completely transformed the way we monitor and manage resident care. The AI-powered insights help our team detect changes in patient conditions earlier, allowing us to intervene quickly and provide better outcomes for our residents.
Gabby Health has completely transformed the way we monitor and manage resident care. The AI-powered insights help our team detect changes in patient conditions earlier, allowing us to intervene quickly and provide better outcomes for our residents.
Gabby Health has completely transformed the way we monitor and manage resident care. The AI-powered insights help our team detect changes in patient conditions earlier, allowing us to intervene quickly and provide better outcomes for our residents.
See how Gabby Health helps you respond first and admit smarter.
Request a DemoFrequently Asked Questions
What is CCM software, and how can a custom-built solution support Medicare-eligible chronic care patients?
Chronic Care Management (CCM) software is a digital platform that helps healthcare providers manage patients with two or more chronic conditions requiring long-term care coordination.
A custom-built CCM solution can:
- Create and manage comprehensive care plans
- Enable non-face-to-face care coordination (calls, messages, follow-ups)
- Track patient progress and clinical interactions
- Ensure compliance with Medicare CCM requirements
- Improve outcomes by reducing hospitalizations and enhancing care continuity
It also integrates workflows like medication tracking, provider collaboration, and patient engagement for better long-term care management.
What Medicare billing requirements (99490, 99439, 99487, 99489) should a custom CCM platform support?
A CCM platform must support key Medicare CPT codes and compliance rules:
- 99490 – At least 20 minutes/month of non-face-to-face care coordination
- 99487 – Complex CCM requiring 60 minutes/month and higher decision complexity
- 99489 – Additional 30-minute increments for complex CCM
Platform requirements:
- Accurate time tracking and logging
- Documentation of clinical activities
- Ensuring only one provider bills per patient per month
- Generating audit-ready reports for compliance
These features are critical because Medicare requires documented proof of time and services delivered.
Can custom CCM software streamline the patient consent workflow required by Medicare?
Yes. Custom CCM software can fully automate and manage consent workflows by:
- Capturing verbal or written consent
- Storing consent securely in patient records
- Providing digital forms and e-signatures
- Tracking consent history and updates
Medicare requires patient consent before starting CCM services and proper documentation for compliance.
How does custom CCM software automate monthly time tracking and documentation for billable minutes?
Custom CCM platforms automate this by:
- Tracking staff activity time automatically
- Logging calls, messages, care coordination tasks
- Categorizing billable vs non-billable activities
- Generating monthly summaries for billing
This is essential because Medicare requires at least 20 minutes of documented care coordination per month for billing eligibility.
Advanced systems also provide:
- Real-time dashboards
- Audit-ready reports
- Alerts for incomplete documentation
How can software support the differences between Regular CCM and Complex CCM under Medicare rules?
A custom solution can differentiate between:
Regular CCM
- Minimum 20 minutes/month
- Moderate care coordination
- Standard care plan management
Complex CCM
- Minimum 60 minutes/month
- Requires moderate to high complexity decision-making
- Frequent care plan revisions
Software handles this by:
- Automatically classifying care level based on time & activities
- Applying correct CPT codes
- Adjusting workflows for complexity
This ensures accurate billing and compliance with Medicare guidelines.
Can custom CCM platforms support combined billing for CCM and RPM in the same month?
Yes, CCM and Remote Patient Monitoring (RPM) can be billed together if requirements for both are met independently.
A custom platform helps by:
- Separating time tracking for CCM and RPM
- Avoiding duplicate billing
- Managing device data and care coordination together
- Ensing compliance with CMS rules
Medicare allows concurrent billing as long as time and documentation are distinct and properly recorded.