EasyLink MD runs the operational side of Chronic Care Management for your organization — from personalized care plans and monthly patient outreach to care coordination and documentation for provider review.
Monthly CCM check-in
22 min
MR
Maria R.
Hypertension · Type 2 diabetes
Medication review
Care plan updated
Next check-in scheduled
You enroll. We operate.
Four steps from consent to documented monthly care — without adding staff.
01
Enroll
Your team identifies or adds qualifying CCM patients, and EasyLink MD manages the ongoing workflow.
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02
Build the Care Plan
Our clinical team creates a condition-specific care plan with goals, interventions, and ongoing care needs.
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03
Monthly Care
Clinical Coordinators conduct structured monthly check-ins, review patient needs, and coordinate follow-up care.
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04
Document & Bill
Care time and monthly activity are documented and organized for provider review.
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One workspace for every CCM patient
Give your care team a centralized view of care plans, monthly activity, patient communication, and required follow-ups.
Track monthly CCM activity and care time
Keep care plans and patient goals organized
Coordinate follow-ups across the care team
Keep documentation organized for provider review
Care plan
Active
Hypertension + Type 2 diabetes
Daily BP readings
6 of 7 days
Medications as prescribed
Cardiology follow-up · Oct 22
Powered by EasyLink MD AI Copilot
CCM, built to make your team’s job easier
Coordinates ongoing care for patients with two or more chronic conditions. Clinical Coordinators handle monthly check-ins and documentation — without adding staff.
AI-Assisted Care Plans
Personalized care plans are drafted around each patient’s diagnoses, goals, and ongoing needs, then reviewed by a clinician before activation.
Guided Monthly Follow-Ups
Clinical Coordinators conduct structured monthly conversations that keep patients engaged and care plans moving forward.
Ongoing Care Coordination
Medication concerns, appointments, referrals, and changes in condition can be surfaced and coordinated throughout the month.
Documentation for Provider Review
Care activity and clinical time are organized for provider review before monthly CCM billing.
What happens during a monthly CCM check-in?
A structured monthly touchpoint that keeps patients engaged, care plans on track, and every interaction documented.
01
Review
Symptoms, medications, and changes since the last contact.
02
Reinforce
Care goals, treatment plans, and patient education.
03
Coordinate
Appointments, referrals, medication issues, and follow-up needs.
04
Document
The interaction and clinical time are documented by your coordinator.
AI call notes
BP readings reviewed
Medication refill needed
Saved to care plan
Why care teams choose EasyLink MD CCM
Extend care beyond the office
Keep patients connected between appointments.
Reduce staff workload
EasyLink MD handles monthly outreach and routine coordination.
Keep care plans moving
Follow-ups help reinforce goals, medications, and next steps.
Simplify monthly documentation
Monthly activity is organized and ready for provider review.
Built for patients managing multiple chronic conditions
CCM helps patients stay supported between visits while giving your care team a structured way to coordinate ongoing care.
Diabetes
Coordinators reinforce medication, diet, and follow-up plans, and keep your team updated on how patients are tracking.
Heart Failure
Structured follow-up helps care teams notice symptom changes early.
Hypertension
Monthly check-ins help patients stay on therapy and flag blood-pressure concerns for your care team.
COPD
Respiratory patients get regular check-ins, medication support, and escalation per your protocols when symptoms worsen.
Chronic Kidney Disease
Care plans keep labs, medications, and specialist follow-ups from falling through the cracks.
Multiple Conditions
CCM is designed for patients managing two or more chronic conditions at once — one plan, one monthly workflow.
Frequently Asked Questions
Answers to common questions about CCM eligibility, monthly care time, escalation, data security, and support.
What is EasyLink MD?
Who is eligible for Chronic Care Management?
How is monthly CCM time documented?
How are clinical issues escalated?
How is patient health data kept secure?
How do I get support and training?
Quality care between visits