Health systems today face immense pressure: rising chronic disease burden, workforce shortages, complex value-based arrangements, readmission penalties, and increasingly high expectations from patients and payors. Episodic care alone cannot address these challenges.
Chronic Care Management (CCM) provides a scalable layer of continuous engagement, enabling systems to intervene earlier, stabilize high-risk populations, and improve long-term outcomes.
CCM provides the following benefits to Health Systems:
- A Predictable Rhythm of Engagement for High-Risk Patients: CCM establishes structured monthly outreach across service lines including cardiology, primary care, endocrinology, pulmonology, and nephrology. This delivers consistent support through medication adherence assessment, symptom monitoring, lifestyle coaching, behavioral support, social determinants of health (SDoH) screening, and goal setting.
- Reducing Avoidable Utilization at Scale: CCM helps systems reduce ED visits, avoidable admissions, readmissions, CHF/COPD exacerbations, and diabetes-related complications. Paired with RPM, early detection improves dramatically.
- Expanding Care Team Capacity Without Expanding Payroll: Kencor Health deploys an integrated care management team composed of care coordinators, RNs/LPNs for clinical escalation, clinical coaches, multilingual support staff, and supervising clinicians who collaborate closely with your existing care teams to ensure seamless, coordinated delivery of CCM services.
Kencor Health Provides A System-Level Technology Platform including:
- Seamless bi-directional EHR integration
- Cross-clinic dashboards
- Care plan templates
- Time tracking and documentation
- Cohort stratification and analytics
- Operational and quality dashboards
Kencor handles enrollment, outreach, staffing, escalations, documentation, compliance audits, and leadership reporting.
Financial Benefits for Health Systems
CCM improves system financial performance by:
- Reducing readmission penalties
- Lowering total cost of care
- Improving MSSP/ACO REACH performance
- Supporting accurate RAF scoring
- Enhancing shared savings
- Increasing patient retention
A Scalable, Modern Care Continuum
With seamless EHR integration, dedicated staffing, and centralized program management, Kencor Health enables health systems to deploy CCM across thousands of patients efficiently.
Ready to transform your chronic care management program? Contact Kencor Health at support@kencorhealth.com or visit our website at www.kencorhealth.com to learn how we can help your health system improve outcomes and strengthen financial performance.
