Care for Patients with Chronic Conditions

75% of Medicare dollars are spent on patients with 2+ chronic conditions. New programs, such as Chronic Care Management require a patient’s entire circle of care be able to access their information and communicate with that patient monthly. Our solution supports the delivery of CCM in a multitude of ways:

Condition-specific disease management including diabetes, heart failure and COPD.

Patients with chronic conditions have no help with the ongoing management of their disease. Medicare created the first payment program to incentivize doctors to provide support to these patients on an ongoing basis. Patients must receive at least 20 minutes of some form of communication a month to help them with med management, care plan review, health goals, education, etc.

Most providers don’t have the adequate technology or staff to deliver CCM in a cost-effective manner. A care plan has to be viewable by patients and specialist, added to and edited at least once a month and adequate documentation and reporting to ensure billed correctly and leaves a good audit trail. Most providers also do not think the monthly payment is enough to cover costs to them and end up using more expensive staffing resources then necessary. Compliance is also tricky as there are numerous components that must be bet on a monthly basis in order to receive payment.

Axial Chronic Care Services

Mobile Messaging
Care Coordination
Med Reconciliation
Chronic Care Management App


Call us and get answers on Transitional Care Management

919 576-9988

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