Chronic Care Coordination at Scale

An MSSP ACO managing 10,000 attributed lives with a typical chronic disease prevalence profile may have 2,500 to 3,500 patients enrolled in active CCM programs. Each of those patients requires, under CMS billing requirements, at least 20 minutes of non-face-to-face care management monthly, documented with a time-stamped record of the interaction. The condition profiles span diabetes, heart failure, COPD, chronic kidney disease, hypertension, and combinations of these — each with its own monitoring cadence, medication protocol, and escalation criteria.

A care coordination team of 10 full-time coordinators managing 3,000 active CCM patients faces a structural caseload problem. Ten coordinators working 40-hour weeks, accounting for documentation, care plan management, and administrative time, have roughly 1,600 to 1,800 available hours per month for patient contact. At 3,000 patients, that is approximately 30 minutes per patient per month — before the time required for any patient who presents a barrier, requires a medication review, or generates a clinical escalation.

The consequences of the caseload gap are not abstract. Patients who do not receive monthly CCM contact do not get their documentation — which affects billing. Patients whose medication barriers are not captured in a routine check-in present with preventable clinical events. The CCM program that is supposed to manage these patients at scale is limited by the same infrastructure that served a smaller panel.

The Chronic and Longitudinal Care Management Agent runs monthly two-way outreach for the full chronic care population — capturing current medication status, identifying barriers, checking for new or worsening symptoms, reinforcing care plan adherence, and routing clinical concerns to the coordinator or care team for follow-up. Every interaction is time-stamped and documented for CCM billing eligibility. The coordinator team receives a daily queue of escalations and exceptions — not a list of 3,000 patients to work through from scratch.

ZynReminder handles the patients who need a follow-up outreach after the initial monthly contact — those who reported a barrier that needed resolution, who agreed to schedule an appointment but have not confirmed, or whose medication concern required a pharmacist callback.

For ACOs where CCM billing represents a meaningful revenue stream alongside the shared savings calculation, the change in monthly contact completion rates directly affects revenue capture. For the care coordination team, the change is operational: coordinators spend their time managing the patients whose situations require clinical judgment, not managing the contact volume for the entire caseload.