Chronic Care Management
A patient has two or more chronic conditions expected to last at least 12 months, or until death.
Explore CCM →Your team, extended between visits
Care management, matched to the patient.
From ongoing conditions to the next step after discharge, MySeema helps your team carry the outreach, coordination and documented follow-through. Explore the programs that fit your patients and your care model.
Connected care. Shared responsibility.Your clinicians direct care. We carry the agreed follow-through.
Start with the need. See how we help.
Each page explains patient fit, the work MySeema can take on, the clinical responsibilities that remain with your team, and, where applicable, a selected service’s revenue estimate. MTM has separate plan and contract arrangements.
Ongoing care
Principal Care Management
One complex chronic condition is expected to last at least three months.
Explore PCM →Advanced Primary Care Management
The patient has an ongoing primary-care relationship with the practitioner who serves as the focal point for needed care.
Explore APCM →After discharge
Transitional Care Management
A patient is returning to a community setting after discharge from a qualifying inpatient or partial-hospital setting.
Explore TCM →Remote monitoring
Remote Patient Monitoring
A clinician determines that monitoring physiologic data at home is medically appropriate for an acute or chronic condition.
Explore RPM →Remote Therapeutic Monitoring
A qualified provider prescribes therapy for a condition within an RTM use case supported by current rules.
Explore RTM →Navigation & behavioral support
Principal Illness Navigation
One serious, high-risk illness is expected to last at least three months.
Explore PIN →Community Health Integration
A practitioner identifies unmet social needs that interfere with medical care during an eligible initiating visit.
Explore CHI →Behavioral Health Integration
The patient has an identified behavioral, mental-health, or psychiatric condition that the treating team will manage in an integrated model.
Explore BHI →Medication support
Medication support & MTM coordination
The patient is enrolled in a Medicare drug plan and is eligible for that plan's MTM program under its current criteria.
Explore MTM →A program is more than a billing code.
A team to carry the work
- Outreach and enrollment support
- Coordination around appointments, referrals and practical barriers
- Documentation, escalation and follow-through in the agreed workflow
An operating model you can review
- Clear responsibilities and qualified roles
- A care plan and clinical escalation pathway
- Documented service activity and monthly partner reporting
Useful evidence for the conversation.
Anwar KaziCEO, IntraCare
ACO partnership experience · IntraCare
“Partnering with MySeema allows us to expand critical programs like remote monitoring and care navigation in a way that supports both patient health and our broader population health strategy.”
From MySeema’s broader care-management partnership.
Read about the partnership →See a real partnership
Read the announced IntraCare ACO relationship and the scope of the care-management work.
IntraCare partnership →Compare your options
Understand where CCM, PCM and APCM fit before deciding how to organize the work.
Compare ongoing care →Make the work visible
See the questions to ask about staffing, documentation, reporting and implementation.
Partnership checklist →Bring us the work that is falling between visits.
We will map the patient population, the coordination we can take on and how the partnership fits your clinical team.