CCM + Geriatrics
Chronic Care Management for Geriatrics — ALIS + CCN Health
Specialized CCM protocols for Geriatrics — integrated with ALIS, powered by CCN Health. Evidence-based workflows, automated documentation, and Medicare billing.
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Not ready for a call? No problem. Drop us a message and we'll get back to you within 24 hours with answers to your questions about Chronic Care Management for your facility.
Tell us about your organization
Share details about your facility, current EHR setup, and what you're looking to achieve.
We'll review and respond
Our team will assess your needs and send you relevant information, case studies, or suggest next steps.
Connect when you're ready
When the time is right, we'll schedule a personalized demo tailored to your workflows.
Send Us a Message
We'll get back to you within 24 hours.
CCN Health provides a certified Chronic Care Management (CCM) integration with ALIS optimized for geriatrics practices. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Chronic Care Management for Geriatrics with ALIS
For geriatrics patients in facilities using ALIS, CCM enables continuous physiological monitoring with data flowing directly into the EHR.
Geriatrics Conditions Managed
- Multi-morbidity
- Frailty
- Polypharmacy management
- Fall prevention
- Cognitive decline
- Malnutrition risk
Clinical Protocols
- Comprehensive vital sign monitoring across multiple conditions
- Fall risk assessment and continuous monitoring
- Medication management with polypharmacy review
- Functional status tracking for aging-in-place support
Key Monitoring Metrics
| Metric | Clinical Significance |
|---|---|
| Blood pressure | Tracked and trended for geriatrics management |
| Weight | Tracked and trended for geriatrics management |
| Heart rate | Tracked and trended for geriatrics management |
| SpO2 | Tracked and trended for geriatrics management |
| Activity levels | Tracked and trended for geriatrics management |
| Sleep patterns | Tracked and trended for geriatrics management |
Recommended Devices for Geriatrics
| Device | Use Case |
|---|---|
| Blood pressure monitor | Geriatrics monitoring |
| Weight scale | Geriatrics monitoring |
| Pulse oximeter | Geriatrics monitoring |
| Xandar Kardian sensorless | Geriatrics monitoring |
| Fall detection sensor | Geriatrics monitoring |
Relevant ICD-10 Codes
- R54 (Age-related physical debility)
- R26.x (Abnormalities of gait and mobility)
- Z73.x (Problems related to life management)
- R41.x (Cognitive function symptoms)
Clinical Evidence
Comprehensive geriatric monitoring programs reduce hospitalizations by 20-35% and support longer independent living periods in senior populations.
Billing & Reimbursement
| CPT Code | Reimbursement | Requirements |
|---|---|---|
| 99490 | ~$62/mo | 20+ minutes of clinical staff time per month |
| 99491 | ~$83/mo | 30+ minutes of physician/QHP time per month |
Monthly potential per patient: $62+
Frequently Asked Questions
How does CCM support geriatrics practices?
CCN Health's CCM integration provides geriatrics-specific monitoring protocols, automated documentation in ALIS, and compliant Medicare billing for multi-morbidity and related conditions.
What devices are recommended for geriatrics CCM?
For geriatrics patients, CCN Health recommends blood pressure monitor, weight scale, pulse oximeter based on the specific conditions being managed.
Can CCM data integrate with specialist workflows?
Yes. All CCM data flows into ALIS and is available for specialist review, care plan updates, and cross-program coordination.
Geriatrics
Geriatrics Protocols — clinical workflows configured to evidence-based guidelines and risk thresholds.
Specialist Coordination — automated alerts and reporting to referring specialists and primary care teams.
Outcome Tracking — longitudinal vitals data mapped to Geriatrics-specific quality measures.
Clinical Documentation — automated notes that satisfy specialist coding and audit requirements.
Purpose-built for Geriatrics workflows — integrated with the EHR your facility already uses.
Configurable Alerts
Set thresholds that match your clinical protocols
Flexible Workflows
Adapt routing, documentation, and permissions to your team
Automated Compliance
Real-time audit trail and billing validation
Advanced technology working behind the scenes — so your team gets faster processing, smarter alerts, and effortless documentation without changing how they work.
Technology that stays in the background — so care stays in the foreground.
Why CCN Health
Why Geriatrics Programs Choose CCN Health
Purpose-built technology that fits your clinical workflows and drives measurable outcomes.
Questions?
Want to learn more about Chronic Care Management for your facility?
Our team can answer your questions and show you how it works with your current workflow.
Seamless EHR Integration
How CCN Health Works Inside ALIS
Your program data flows directly into ALIS — no exports, no manual entry, no disruption to your clinical workflow.
Care Coordination
Calls, Assessments, Care Plans
Built Around How You Operate
Custom workflows, smart alerting, and automated documentation — advanced technology working behind the scenes so your team doesn't have to.
ALIS
Charts & Care Plans
What Flows Between Systems
Patient Demographics
Chronic conditions, medications, and problem lists from your EHR
Care Plan Updates
Treatment plans and goals sync bi-directionally
Contact Logging
Phone calls and check-ins documented with timestamps
Medication Reconciliation
Current medication lists kept in sync across platforms
Time Tracking
Care management minutes tracked for billing compliance
Billing Documentation
CPT 99490/99491 records generated automatically
“Every reading, every alert, every care plan update — available across all your programs. One integration, unlimited use cases.”
Infrastructure
Medicare Billing
Automated Medicare billing documentation — every qualifying encounter captured and coded.
Medicare Billing
Chronic Care Management (CCM)
3 billing codes
First 20 minutes of clinical staff time for CCM services
~$62
Monthly
Each additional 20 minutes of CCM clinical staff time
~$47
Monthly (additional)
First 30 minutes of physician/QHP time for complex CCM
~$83
Monthly
Common Questions
Frequently Asked Questions
Everything you need to know about Geriatrics — implementation, billing, and clinical workflows.
Yes. CCN Health integrates with the ALIS platform so that RPM readings sync directly into resident records, streamlining clinical workflows for senior living communities.
CCN Health transmits device data to ALIS through a secure API, ensuring vitals are available to caregivers inside the EHR they already use every day.
CCM is a Medicare program that reimburses providers for non-face-to-face care coordination for patients with two or more chronic conditions, billed under CPT codes 99490, 99439, and 99491.
Most facilities are fully operational within 2–4 weeks. CCN Health handles device provisioning, EHR integration setup, staff training, and ongoing clinical support.
Still have questions? We're happy to walk you through anything.
Contact Us
Prefer to Send a Message?
Not ready for a call? No problem. Drop us a message and we'll get back to you within 24 hours with answers to your questions about Chronic Care Management for your Geriatrics program.
Tell us about your organization
Share details about your Geriatrics program, current EHR setup, and what you're looking to achieve.
We'll review and respond
Our team will assess your needs and send you relevant information, case studies, or suggest next steps.
Connect when you're ready
When the time is right, we'll schedule a personalized demo tailored to your workflows.
Send Us a Message
We'll get back to you within 24 hours.
Get Started
Ready to bring Chronic Care Management to your Geriatrics program?
See how CCN Health can improve patient outcomes, support specialist coordination, and generate new Medicare revenue — all within the EHR your staff already uses.