CCM · Blood Glucose
Blood Glucose Monitoring for Home Health CCM — MatrixCare + CCN Health
Blood Glucose Monitoring technology powering your CCM program in Home Health — fully integrated with MatrixCare. 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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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 MatrixCare designed specifically for home health agencies, featuring glucose monitoring technology. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Glucose Monitoring for Home Health CCM with MatrixCare
Home Health agencies can enhance their CCM programs with glucose monitoring technology that integrates directly with MatrixCare. FDA-cleared blood glucose meters from Trividia Health and Smart Meter use fingerstick testing with automatic cellular transmission. Results transmit to the CCN Health platform within minutes without patient interaction beyond the test itself.
Why Glucose 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. Glucose Monitoring is particularly relevant because:
- Familiar fingerstick method — minimal learning curve
- Automatic cellular transmission eliminates manual logging
- Real-time alerts for dangerous highs (>300) and lows (<70)
How Glucose Monitoring Works
FDA-cleared blood glucose meters from Trividia Health and Smart Meter use fingerstick testing with automatic cellular transmission. Results transmit to the CCN Health platform within minutes without patient interaction beyond the test itself.
Data Captured
- Fasting blood glucose
- Postprandial glucose
- Blood glucose trends
- Hypoglycemia events
- Hyperglycemia events
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.
Glucose Monitoring vs. Traditional Approaches
| Factor | Glucose Monitoring | Traditional |
|---|---|---|
| Test Method | Fingerstick with auto-upload | Fingerstick with manual logging |
| Data Transmission | Cellular — instant to platform | Paper log or manual entry |
| Alert Capability | Real-time hypo/hyperglycemia alerts | No alerting — reviewed later |
| Cost | Lower than CGM | Similar test strip costs |
| Clinical Oversight | 24/7 monitoring with escalation | Reviewed at appointments |
Common Conditions in Home Health
- heart failure
- COPD
- diabetes
- post-surgical
- wound care
- medication management
Billing & Reimbursement
Glucose 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 glucose monitoring suitable for home health patients?
Yes. Glucose Monitoring is ideal for home health settings, where familiar fingerstick method — minimal learning curve.
How does glucose monitoring data reach MatrixCare?
Data flows automatically from the monitoring system to CCN Health's platform, then syncs bi-directionally with MatrixCare. No manual charting required.
What is the implementation timeline?
Most home health agencies are fully operational within 4 weeks including system deployment, MatrixCare 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 MatrixCare
Your program data flows directly into MatrixCare — 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.
MatrixCare
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 MatrixCare to deliver monitoring data into post-acute care workflows, supporting RPM and CCM programs across skilled nursing and senior living.
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 a connected blood glucose meter to take readings that transmit automatically to CCN Health's platform, supporting diabetes management with real-time trend visibility for clinicians.
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 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.