Patients in your chronic care programs need a touchpoint every month. Agents run the routine check-ins, and care managers spend their time on the patients who need them.
Chronic care management asks for a documented touchpoint every calendar month for each enrolled patient. Across an attributed population, that is thousands of calls on top of transitions, quality gaps and wellness visits.
When the month runs out, the routine check-ins are what slip, and those are the calls that catch a missed medication or a new symptom before it becomes an admission.
The care plan sets the cadence and the questions. Care managers get a queue of exceptions, not the whole list.
Due patients, by risk tier. Enrolled patients due for a touchpoint are ranked by risk tier and date of last contact.
The monthly check-in. The agent asks about symptoms, medications and upcoming visits, reinforces the care plan and records the contact.
Changes go to a care manager. New symptoms, missed doses and barriers are escalated by rule, with the conversation attached.
Time and documentation are reviewed. The billing provider reviews the record and decides what counts toward CCM time.
Visits booked when needed. If the care manager wants the patient seen, ZynSchedule books the visit.
Agents escalate, clinicians decide. Agents follow the escalation rules your team sets and hand clinical questions to a licensed clinician. They don’t diagnose or recommend treatment.
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