Chronic Care Management with Integrated CMS Care, Tailored to Patients
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 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.
Learn more about government CCM and PCM guidelines > Care Management Services (CMS)
Cosán’s approach to CCM goes beyond the basics to provide a highly advanced and comprehensive care coordination program.
The Benefits of Cosán’s CCM Program
Cosán Chronic Care Management helps providers identify and address patient needs more quickly to help reduce complications and readmissions. Providers receive real-time data about changes in patients’ health, as well as evidence-based insights, so they can treat symptoms before they become urgent.
Practices and patients gain with:
Goal Realization: CCM helps patients achieve health goals through regular guidance, progress tracking, and personalized care adjustments.
Treatment Compliance: Improve adherence to treatment plans by providing consistent support and clear communication.
Reinforcement of Post-Visit Instructions: Care Coordinators clarify and reinforce provider instructions after appointments, ensuring better follow-through and outcomes.
Proactive Risk Management: Ongoing monitoring identifies risks early, enabling timely interventions to prevent complications.
Better Outcomes: CCM reduces hospitalizations, improves chronic care, and lowers costs through sustained patient engagement and effective care coordination.
Cost-effective options for monthly between-office visits with a trusted resource integrated into the provider workflow and support staff.
More Cosán Services:
Chronic Care Management
Cosán empowers providers to offer Chronic Care Management as a seamless extension of their existing care model, helping improve outcomes while supporting practice sustainability.
Remote Patient Monitoring
Remote Patient Monitoring helps practices actively manage symptoms of chronic or acute conditions from home.
Nutrition Support
Nutrition Support is an education-focused program that supports patients in meeting their nutrition goals.
Access and Equity at Scale
Learn more about what Cosán has to offer.
