apollo health

chronic care monitoring

Chronic Care Monitoring in Gig Harbor, WA

chronic care monitoring

Understanding CCM:

Chronic Care Management (CCM) is non-face-to-face services provided to patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.

In addition to office visits and other face-to face encounters (billed separately), these services include communication with the patient and other treating health professionals for care coordination (both electronically and by phone), medication management, and being accessible 24 hours a day to patients and any care providers (physicians or other clinical staff). The creation and revision of electronic care plans is also a key component of CCM.  The designated CCM clinician must establish, implement, revise, or monitor and manage an electronic care plan that addresses the physical, mental, cognitive, psychosocial, functional and environmental needs of the patient as well as maintain an inventory of resources and supports that the patient needs. Only one clinician can bill for any particular patient therefore it may be necessary to coordinate with the sub-specialists who may be providing a significant amount of care and treatment to one or more of the patient’s conditions. It will be important that the patients understand only one of their likely multiple physicians will be able to bill for CCM services. These codes are generally intended for use by the clinician who is providing the majority of the care coordination services, which most often would be the primary care internist.

Examples of chronic conditions include, but are not limited to, the following:

  • Alzheimer’s disease and related dementia
  • Arthritis (osteoarthritis and rheumatoid)
  • Asthma
  • Atrial fibrillation
  • Autism spectrum disorders
  • Cancer
  • Cardiovascular Disease
  • Chronic Obstructive Pulmonary Disease
  • Depression
  • Diabetes
  • Hypertension
  • Infectious diseases such as HIV/AIDS

For more information please see the following link:


Note – Even if you don’t have 2 or more chronic conditions but wish to participate in a tailored program unique to your needs, please contact us to discuss.


  • There is nobody better trained to manage complex chronic care conditions than internal medicine physicians. This is the core of what we do at Apollo.
  • We have extensive experience in all major disease states as well as healthcare systems and organizations.
  • We have the ability to manage chronic conditions better and more cost effectively
  • We help you navigate any and all challenges as they crop up.
  • The end result → healthier happier patients and families.

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