Chronic Care Management: Home



We empower patients, providers, healthcare organizations and payers with evidence-based, high quality in-between visit chronic care management technology and clinical services.

Dr. William Mills, a board-certified home-based primary care physician, founded Chronic Care Management, Inc. in early 2015 after  years of caring for complex patients within the fee-for-service Medicare system. Striving to build a system to provide better support for people with chronic conditions in-between their provider visits or episodes of care, Mills partnered with Medicare to develop a comprehensive technology and clinical services platform to help deliver on the promise of “in-between visit care”.  The team at CCM Inc. is singularly focused on providing real world solutions for healthcare providers and other stakeholders to enhance the manner in which people with chronic conditions receive care. The team is currently helping people in 27 states in the U.S. use the new Medicare benefit and is partnering with healthcare organizations to achieve successful outcomes.

How CCM Connects Care

ANNA Connected Care™
Using mobile / smartphone enabled patient outreach initiated by ANNA, high impact care management questions are asked of patients to determine current risk.  ANNA then triggers live engagement with care team members, physicians and appropriate community resources.

ANNA Connected Care™ Provider Platform
ANNA Connects CCM physicians/providers with regular updates/alerts enabling physicians to review CCM care plans and address identified risks proactively.

Chronic Care Management (CCM)

  • Our CCM program helps organizations succeed in both fee-for-service and value-based care models
  • Capture valuable fee-for-service revenue under Chronic Care Management CPT Codes
  • Evidence-based, actionable data-driven care management helps bend total cost curve downwards
  • CCM specializes in identifying “in-between visit” risks and connecting the patient’s care team to mitigate risks, affecting preemptive, quality care
  • Portable, person-centered care plans
  • Best-in-class time tracking and documentation solution for CCM

Quality Payment Program Support within ccm workflow (ACO, MIPS)

  • We support all major Medicare quality payment programs as part of our care management workflows with winning results
  • By integrating ACO or MIPS quality measures into CCM workflow, we help groups drive quality improvement
  • We are helping practices drive significant improvements in their level of quality measure attainment
  • Our leadership team has unique experience in quality care management for high risk patients