Chronic Care Management Services: Supporting Your Care

The Streamlined, Compliant Way to Manage Resource-Intensive Patients

If you’re a primary care physician, you already know that patients with chronic conditions are more likely to present with time-consuming problems that put you in the role of care coordinator while keeping your office from operating at maximum efficiency.

The Lacuna Health Solution
At Lacuna Health, our chronic care management services benefit our practice partners in a number of ways:

  • Conducting monthly, non-face-to-face conferences of at least 20 minutes with these patients, helping your office meet the requirements of CPT 99490*
  • Offering a care management team aligned with CMS requirements to provide aid and navigation
  • Developing comprehensive care plans that are reviewed and approved by a practice physician
  • Effecting medication reconciliation to avoid error and support patient compliance
  • Keeping physicians notified about a patient visit to an ER, hospital or SNF
  • Coordinating with specialists as well as home- and community-based service providers

These services provide continuity of care between office visits and help aggregate clinical and patient information to create a holistic perspective of the patient’s care. We can even connect to your EHR, allowing our CCM care team to review necessary patient care information.

Experts estimate that patients with multiple chronic conditions are responsible for:

70% of all inpatient stays1

75% of typical primary care visits2

93% of Medicare spending3

Lacuna Health Physician Practice Solutions for evolving CMS care management programs:

  • Chronic Care Management
  • Transitional Care Management
  • Remote Patient Monitoring
  • Advanced Care Planning
  • Behavioral Health Integration

Implementing CCM in a Way That 

  • For Practicesevery encounter is properly tracked for fully CMS compliant outreach.
  • For Patients: reassurance comes through contact with a trusted, nurse-led team of care coordinators who assist in care navigation and coordination.
  • For Organizations: results come in improved clinical and financial performance, filling gaps in care and patient adherence.

At Lacuna Health, we fill gaps in your patients’ recovery journeys with expert clinicians who are as adept in medicine as they are in strengthening the nexus between care quality, outcomes and cost.


Lacuna Health: The Leading Provider of Patient Engagement Solutions
Lacuna Health, a care management solutions company, is a leading provider of patient engagement and placement solution services. At Lacuna Health, our inbound and outbound patient engagement solutions are provided by a highly qualified and specifically-trained team of nurse advocates, each armed with the data and technology needed to engage your patients at the right time, in the right place, in the right way. Through our patient engagement services, we identify gaps in care and match patient needs to appropriate care management solutions and community resources. This proactive approach to patient engagement enables Lacuna Health to serve its customers by helping their patients maintain optimal levels of independence at home. At Lacuna, we have a deep understanding of the issues facing today’s healthcare system and offer care management solutions specifically designed to leverage the proven advantages of successful patient engagement. Contact us today to learn more.

* The CPT codes provided are based on American Medical Association guidelines and are for informational purposes only. CPT coding is the sole responsibility of the billing party. Please direct any questions regarding coding to the payer being billed.

1. Gallup Organization. Unhealthy U.S. workers’ absenteeism costs $153 billion. October 13, 2011. Available at
2. Zamosky L. Chronic disease: a growing challenge for PCPs. Med Econ. Available at
3. Gerteis J, Izrael D, Deitz D, et al. Multiple chronic conditions chartbook. AHRQ Publications No. Q14-0038. Rockville, MD: Agency for Healthcare Research and Quality; 2014.