CCM for Skilled Nursing
Chronic Care Management for Skilled Nursing — Powered by PointClickCare + CCN Health
Purpose-built CCM for Skilled Nursing communities. CCN Health integrates directly with PointClickCare to automate clinical workflows and capture every eligible reimbursement.
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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 Skilled Nursing.
Tell us about your organization
Share details about your Skilled Nursing, 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 PointClickCare designed specifically for skilled nursing facilities. The platform automates clinical documentation, enables real-time monitoring, and generates Medicare billing records for compliant reimbursement.
Chronic Care Management for Skilled Nursing with PointClickCare
Skilled Nursing facilities face unique challenges managing resident health: managing high-acuity patients with multiple comorbidities and reducing 30-day hospital readmission rates. CCN Health's CCM integration with PointClickCare addresses these challenges with automated monitoring, documentation, and billing.
Skilled Nursing Challenges That CCM Addresses
- Managing high-acuity patients with multiple comorbidities
- Reducing 30-day hospital readmission rates
- Meeting CMS quality measures and star ratings
- Maintaining survey readiness with comprehensive documentation
How It Works in Skilled Nursing
- Patient Enrollment — Identify Medicare patients with 2+ chronic conditions and obtain consent
- Care Plan Creation — Develop comprehensive care plan addressing all chronic conditions
- Monthly Coordination — Regular check-ins, medication reconciliation, and care plan updates
- PointClickCare Documentation — Care coordination notes and time logs sync to PCC automatically
- Billing Automation — Time tracking and documentation for CPT 99490/99491 generated automatically
Why Skilled Nursing Facilities Choose CCN Health
Readmission Prevention
Continuous monitoring during the critical post-acute window reduces hospital readmissions and improves quality scores.
Quality Measures
Objective vital sign data supports CMS quality reporting and star rating improvement efforts.
Survey Readiness
Comprehensive, timestamped records provide audit-ready documentation for state and federal surveys.
Acute-Level Monitoring
Continuous vital sign capture supports the higher-acuity clinical needs of skilled nursing residents.
Devices for Skilled Nursing CCM
| Device | Use Case | Resident Experience |
|---|---|---|
| Care Coordination Platform | Multi-condition management | Centralized dashboard for all chronic conditions |
| Medication Tracking | Adherence monitoring | Automated refill reminders and reconciliation |
| Secure Messaging | Patient communication | HIPAA-compliant messaging for monthly check-ins |
Clinical Benefits for Skilled Nursing
Chronic Disease Management
Monitor residents with conditions like post-surgical recovery, heart failure, pneumonia, COPD exacerbation. Trending data helps clinical teams adjust care plans before conditions deteriorate.
Transition of Care Support
When residents return from hospital stays, CCM enables closer monitoring during the critical post-discharge period.
Billing & Reimbursement in Skilled Nursing
CCN Health automates Medicare CCM billing documentation for qualified residents:
| 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 resident: $62+
Frequently Asked Questions
Does CCN Health integrate with PointClickCare for skilled nursing CCM?
Yes. CCN Health's certified PointClickCare integration enables bi-directional data flow specifically designed for skilled nursing workflows.
What is the implementation timeline for skilled nursing?
Most skilled nursing facilities are fully operational within 4 weeks, including integration setup, nursing staff training, and device deployment.
How does CCM billing work in skilled nursing?
CCN Health automatically documents the required data for 99490, 99491. Time tracking and transmission records are captured for audit-ready Medicare billing.
Implementation for Skilled Nursing
| Week | Activity |
|---|---|
| 1 | Discovery call and PointClickCare configuration review |
| 2 | Technical integration setup and testing |
| 3 | Nursing staff training and device deployment |
| 4 | Pilot launch with select residents |
| 5+ | Full facility rollout and optimization |
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 Skilled Nursing 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 Skilled Nursing 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 Skilled Nursing?
Our team can answer your questions and show you how it works with your current workflow.
Seamless EHR Integration
How CCN Health Works Inside PointClickCare
Your program data flows directly into PointClickCare — 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.
PointClickCare
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 implementation, billing, and clinical workflows.
Yes. CCN Health has a direct integration with PointClickCare, allowing vital-sign data from RPM devices to flow automatically into resident charts without manual entry.
Device readings are transmitted to CCN Health's platform and then pushed into PointClickCare via API, appearing alongside existing clinical documentation for a unified workflow.
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.
Skilled nursing facilities use RPM to continuously monitor residents' vitals, enabling early detection of decline, reducing hospital transfers, and supporting compliance with quality reporting requirements.
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 Skilled Nursing.
Tell us about your organization
Share details about your Skilled Nursing, 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 Skilled Nursing?
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.