CCM · Blood Pressure
Blood Pressure Monitoring for Home Health CCM — Epic + CCN Health
Blood Pressure Monitoring technology powering your CCM program in Home Health — fully integrated with Epic. Real-time alerts, clinical workflows, and automated billing in one platform.
Hundreds of facilities just like yours have grown their Chronic Care Management programs with CCN Health. .
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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 Home Health.
Tell us about your organization
Share details about your Home Health, 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 Epic designed specifically for home health agencies, featuring bp monitoring technology. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
BP Monitoring for Home Health CCM with Epic
For home health agencies running CCM through Epic, bp monitoring addresses a critical need: monitoring patients between home visits when clinicians are not present. FDA-cleared automated cuffs from Smart Meter (iBloodPressure), Omron, Bodytrace, and Telli Health measure systolic/diastolic pressure and heart rate with a single button press. Readings transmit automatically via cellular gateway to the CCN Health platform.
Why BP Monitoring for Home Health
Home Health agencies serve patients receiving skilled nursing or therapy services in their homes, often managing chronic conditions between agency visits. BP Monitoring is particularly relevant because:
- One-button operation — no technical skill required
- Automated cellular transmission eliminates manual recording
- Multiple daily readings capture true BP patterns vs. office visits
How BP Monitoring Works
FDA-cleared automated cuffs from Smart Meter (iBloodPressure), Omron, Bodytrace, and Telli Health measure systolic/diastolic pressure and heart rate with a single button press. Readings transmit automatically via cellular gateway to the CCN Health platform.
Data Captured
- Systolic blood pressure
- Diastolic blood pressure
- Heart rate
- Mean arterial pressure
- Pulse pressure
Benefits for Home Health Agencies
Between-Visit Monitoring
Continuous data capture fills the gaps between scheduled home visits with objective vital sign data.
Reduced Hospitalizations
Early alerts enable clinical response before conditions require emergency department visits.
Clinician Efficiency
Automated charting reduces documentation burden, allowing clinicians to focus on direct patient care.
BP Monitoring vs. Traditional Approaches
| Factor | BP Monitoring | Traditional |
|---|---|---|
| Readings Per Day | Multiple scheduled readings | 1-2 manual checks |
| Data Accuracy | Validated FDA-cleared devices | Subject to observer technique |
| Trend Visibility | Real-time dashboards and alerts | Paper logs reviewed at appointments |
| Staff Burden | Automated — no manual charting | Manual BP check and documentation |
| Response Time | < 2 min alerts for critical readings | Discovered at next scheduled check |
Common Conditions in Home Health
- heart failure
- COPD
- diabetes
- post-surgical
- wound care
- medication management
Billing & Reimbursement
BP Monitoring data contributes to CCM billing in home health settings:
| 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
Is bp monitoring suitable for home health patients?
Yes. BP Monitoring is ideal for home health settings, where one-button operation — no technical skill required.
How does bp monitoring data reach Epic?
Data flows automatically from the monitoring system to CCN Health's platform, then syncs bi-directionally with Epic. No manual charting required.
What is the implementation timeline?
Most home health agencies are fully operational within 4 weeks including system deployment, Epic integration, and clinical team training.
Discovery call — we learn your workflows, EHR setup, and patient population so nothing gets lost in translation.
We configure your platform around how your team actually operates — custom alert thresholds, EHR data mapping, and role-based permissions.
Go live with monitoring, automated documentation, and billing tailored to your practice — your team stays focused on care.
No one-size-fits-all templates. Every integration is configured for how your Home Health actually operates.
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 Home Health Facilities 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 Home Health?
Our team can answer your questions and show you how it works with your current workflow.
Seamless EHR Integration
How CCN Health Works Inside Epic
Your program data flows directly into Epic — 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.
Epic
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
Devices & Billing
FDA-cleared devices and automated Medicare billing — configured per resident, synced with the EHR.
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 implementation, billing, and clinical workflows.
Yes. CCN Health integrates with Epic via secure APIs, enabling RPM device data and care management documentation to flow into Epic's enterprise health records.
CCN Health transmits device readings and care coordination notes to Epic through FHIR-based APIs, ensuring clinical data is available within existing Epic workflows.
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.
Home health agencies use RPM to monitor patients between visits, receive real-time alerts for concerning readings, and document care coordination to support billing and compliance.
Patients use an FDA-cleared connected blood pressure cuff that automatically transmits readings to CCN Health's platform, enabling clinicians to track trends and intervene early on hypertension or hypotension.
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 Home Health.
Tell us about your organization
Share details about your Home Health, 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 Home Health?
See how CCN Health can improve resident outcomes, preserve independence, support family engagement, and generate new Medicare revenue — all within the EHR your staff already uses.