Chronic Care Management (CCM)

PharmD Live’s CCM program connects patients, pharmacists, and providers for continuous engagement and proactive management.

Comprehensive Support for Patients with Multiple Chronic Conditions

Chronic diseases drive 90 % of U.S. healthcare expenditures, and medication therapy problems (MTPs) such as nonadherence, adverse drug interactions and inappropriate prescribing complicate management. PharmD Live’s CCM program addresses these challenges with a pharmacist‑led, AI‑enabled approach. Our clinicians conduct monthly care plan development, medication reconciliation and patient engagement to improve outcomes and generate recurring revenue via CCM CPT codes.

Core Components of Effective Chronic Care Management

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Medication Therapy Management

Pharmacists perform comprehensive medication reviews, resolve MTPs and deprescribe when appropriate

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Monthly Care Plan and Follow‑Ups:

Patients receive personalized care plans and monthly check‑ins to monitor progress and adjust therapy.

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Remote Monitoring & Telehealth

Integrate RPM and RTM to track vitals and adherence, enabling early intervention.

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AI‑Driven Analytics

Predict nonadherence risks and recommend personalized interventions

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Care Coordination

Collaborate with PCPs, specialists and care managers to ensure seamless communication and shared decision making.

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Billing & Compliance Support

Automated documentation and billing workflows ensure accurate reimbursement for CPT 99490, 99439, 99487 and other codes.

Benefits & Impact of Chronic Care Management

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Reduced Hospitalizations & ED Visits

In a six‑month study, pharmacists resolved 2,875 MTPs and saved $8.6 million in healthcare costs, reducing hospitalizations and ER visits

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Enhanced Quality Scores

CCM addresses chronic disease metrics (e.g., diabetes A1c control, hypertension management) and improves CAHPS scores through proactive patient engagement.

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Financial Sustainability

Recurring CCM reimbursements create new revenue streams while aligning with value‑based care models

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Improved Medication Adherence

Continuous engagement and AI alerts prevent lapses in therapy

Why PharmD Live

Our CCM solution is powered by board‑certified pharmacists who specialize in chronic disease and medication management. We leverage AI‑driven telehealth tools to monitor adherence, predict risks and provide real‑time interventions. By integrating with APCM, RPM and TCM, we ensure patients receive comprehensive, coordinated care while providers benefit from optimized workflows and higher quality performance.