Comprehensive Care Management Advantages


No new technology to learn. Your organization’s EHR remains the database of record for all care management.  Our team communicates with your team using direct secure messaging to your EHR.


We have multi-disciplinary virtual clinical and support teams available 24/7/365.  We are a seamless and transparent extension of your organization.


Care plans are living documents that take into account all aspects of a patient’s well-being including behavioral, physical and social.  All stakeholders and community resources are engaged to address a patient’s ongoing needs.


Synchronous and Asynchronous communications between your patients and our care team are secure and fully integrated, and project your organization’s branding.


We consistently monitor both the payers and the literature to identify best practices for evidence-based Care Management.

Care Solutions

Virtual Care Management

A successful & fully integrated Virtual Care Management strategy for your healthcare organization should include:

- Patient identification, referral, enrollment

- Team-Based Clinical pathways that use virtual multidisciplinary staff

- Seamless expansion of on-site care engagement to the patient’s home

- 24 hour access to your care team

- Evolving plans of care

- Ongoing treatment, assessment, and measurement for optimal outcomes

“No longer just a convenient enhancement to in-person clinical care, virtual care is needed by patients, clinicians, care teams, and health systems alike.”​

Comprehensive Patient Monitoring

CCARE HEALTH is your single source for the technology, devices, logistics and support teams for patient enrollment, readings adherence & compliant engagement.

24/7 Alerts Management with updates to your clinical team through your EHR.

Remote Patient Monitoring, Remote Therapeutic Monitoring, Continuous Glucose Monitoring. The right devices and assessments based upon a patient’s diagnoses.

Diabetes Prevention

1 in 3 adults have pre-diabetes. CCARE HEALTH and its strategic partners have worked with state medical societies, payers, the YMCA, and the AMA to develop and manage a fully interoperable Diabetes Prevention Program (DPP) linking treating physicians with Community Based Organizations for DPP education and health coaching.

Effective Care Management for patients with Diabetes is a collaborative process using tech-enabled interactive patient & care team communication and coaching - for medication adherence, healthy behaviors and compliance with blood glucose biometric readings.

“The American Diabetes Association recommends using a team-based approach to optimize care for patients with diabetes. However, primary care clinics often do not have the resources to have inter-professional teams on site. Telemedicine can bring inter-professional team-based care to patients”​

Behavioral Health Integration

Behavioral Health Integration (“BHI”) reimburses physicians and non-physician practitioners when integrating behavioral health care with primary care delivery.

CCARE supports the Collaborative Care Model of BHI by adding the necessary care management systems and virtual care teams – including psychiatric inter-specialty consultation and specially trained BHI Care Coordinators for patients receiving treatment for mild to moderate behavioral health diagnoses.

Social Determinants of Health

Social Determinants of Health (SDOH) can have a significant impact on effective Care Management. CCARE HEALTH has partnerships with Community Based Organizations (CBOs) who can deliver local resources to meet the SDOH needs of each unique patient we help your organization care for.

Digital Assessments

Pre-scheduled calls and texts to participating patients based on each patient’s individual Care Plan.

SIMPLE: One click from a pre-programmed text transfers the patient to our/your branded & secure portal for patient care management.

The patient is presented with targeted interactive content built on principles from the evolving science of Behavior Change Messaging: “nudging”

All interaction by the patient with the content is measured in real-time.

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