Chronic Care Management (CCM)

The Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a vital part of comprehensive primary care.

Since 2015, Medicare has reimbursed providers for delivering CCM services to beneficiaries with multiple chronic conditions.

Cosán empowers providers to offer CCM (CPT 99490) as a seamless extension of their existing care model, helping improve outcomes while supporting practice sustainability.

Cosán’s mission is to deliver transformative care management technology and services that drive better quality outcomes for patients and stronger financial outcomes for practices.

We specialize in “in-between-visit care”, addressing the moments that matter most between scheduled appointments. Our care coordination model helps providers navigate the complexities of chronic condition management while staying closely connected to patients.

The CCM program pairs patients with a dedicated Care Coordinator and a Multi-disciplinary Care Team to collaborate with their providers in creating personalized, disease-specific care plans. These plans may include:

• Disease-Specific Modules: Care Coordinators conduct regular calls to assess risk, track symptom changes, and gather detailed data about patients’ conditions.
• Symptom Reporting: Changes in symptoms reported by patients are documented in care plans and updated in the practice’s EHR/EMR.
• Medication & Scheduling Support: Care Coordinators assist with medication management, refill requests, and appointment scheduling.
• Patient Education: Guides provide resources on health education, practice initiatives (e.g., vaccinations, screenings), and community services like transportation and support groups.
• Team Communication: Cosán’s team coordinates closely with practice staff to improve care transparency and reduce administrative burden.

This program fosters stronger engagement and connection between patients, caregivers, and healthcare teams.

Patients in long-term care often have multiple chronic conditions but limited provider contact, risking critical health details being missed. Over 80% of Medicare beneficiaries manage multiple chronic conditions, contributing to over 70% of healthcare spending and high hospitalization rates.

CCM is proven to reduce hospitalizations and boost patient engagement. Cosán simplifies implementation by linking patients, providers, families, and care facilities through a unified, evidence-based care plan that is continuously updated with real-time health insights.