SERVICES
Ongoing chronic care support that grows with the practice.
After the CCM Discovery Program establishes fit, EchoCarePlus provides the ongoing structure practices need to deliver chronic care support month after month. The model is built not only to sustain recurring patient support, but also to help the clinic grow CCM enrollment over time and gradually expand the scope of services EchoCarePlus can provide within trusted, provider-aligned boundaries.
Monthly pharmacist-led follow-up, medication counseling, and care-plan reinforcement
Ongoing identification and enrollment of eligible patients to grow the CCM program
Gradual expansion of clinical support within provider trust and agreed scope
Provider-directed lifestyle goal support with HIPAA-compliant tracking tools
Structured documentation, reporting, and clinic communication aligned to workflow
CORE SERVICES
What EchoCarePlus supports after the CCM Discovery Program.
The ongoing service model is built to help the practice maintain structured chronic care delivery after the initial program has been evaluated. Support centers on recurring patient follow-up, provider communication, documentation, and practical reinforcement of the care plan between office visits.
PATIENT SUPPORT
Pharmacist-led monthly follow-up and medication reinforcement
EchoCarePlus provides recurring patient outreach between visits with medication counseling, care-plan reinforcement, adherence support, and clinical follow-through that goes beyond administrative check-ins.
CARE PLANNING
Provider-directed lifestyle goals and patient-centered action planning
Patients are supported with achievable lifestyle goals based on provider recommendations, clinical guidance, and personal motivation, with QR-code access to HIPAA-compliant tools for tracking, reflection, and adaptation over time.
DOCUMENTATION
EHR-aligned documentation and concise provider communication
The clinic receives structured updates, monthly follow-up documentation, and care summaries that help providers stay informed without sorting through fragmented outreach work.
COORDINATION
Support across conditions, referrals, and care-plan follow-through
EchoCarePlus supports patients living with multiple chronic conditions by reinforcing prevention, self-management, specialist follow-up, and the connected care plan the practice wants carried forward between visits.
HOW THE SERVICE SUPPORTS THE PRACTICE
Ongoing support that reduces friction instead of adding to it.
EchoCarePlus is designed to make chronic care support more sustainable for the clinic. The goal is to reduce staff burden, increase visibility, and keep patients engaged without turning the program into another disconnected operational layer.
Reduce the pressure to build the entire program internally
EchoCarePlus gives the practice a working chronic care structure without requiring the clinic to create a separate outreach department, absorb new payroll, or improvise every monthly step on its own.
LESS INTERNAL BURDEN
Extend continuity of care between office visits
Patients receive reinforcement and support between appointments so care plans, medication changes, and provider-directed goals do not lose momentum once the visit ends.
PATIENT CONTINUITY
Keep providers informed with clear, usable updates
Providers receive concise reporting on outreach, billing-related activity, patient progress, and follow-up needs so office visits can be more focused and efficient.
CLEAR VISIBILITY
PROGRAM GROWTH
Grow the CCM program beyond the initial patient cohort.
After the CCM Discovery Program, EchoCarePlus continues helping the practice identify eligible patients, support enrollment, and expand the program at a pace the clinic can sustain. Growth is meant to be deliberate, measurable, and aligned with the practice's real workflow capacity.
Identify more eligible patients over time
EchoCarePlus helps the practice continue identifying Medicare patients who qualify for CCM and are most likely to benefit, moving beyond the initial cohort toward broader, sustainable enrollment.
ELIGIBILITY GROWTH
Track growth against real operational and billing signals
The practice can monitor enrollment activity, billable time, patient engagement, and workflow performance in a way that helps decide when and how to continue expanding the CCM program.
ENROLLMENT MOMENTUM
Grow enrollment at the clinic's pace
Enrollment does not need to happen all at once. EchoCarePlus supports steady program growth using the clinic's preferred techniques so staff and patients experience one coordinated team rather than a separate vendor process.
WEEKLY REVIEW
EXPANDING CLINICAL SUPPORT
Widen the scope of support as trust and collaboration deepen.
EchoCarePlus is designed to prove value over time and then take on more within its agreed role. As provider confidence grows, the service can support a broader set of chronic care activities while staying aligned with clinic expectations, collaboration agreements, and the provider's clinical leadership.
Expand support gradually within provider trust and agreed scope
EchoCarePlus is designed to widen its support over time as the clinic gains confidence in the model. Services expand deliberately, with provider alignment and clear boundaries that preserve trust.
TRUSTED EXPANSION
Support care-gap closure and value-based performance goals
EchoCarePlus can also work alongside the clinic and its ACO to support care-gap closure, quality metric follow-through, and stronger value-based reimbursement opportunity without overstepping the provider's role.
CLINICAL SCOPE
Add deeper clinical support as the relationship matures
That growing scope can include more comprehensive questionnaires, social determinants of health review, pharmacist-led medication review, and guideline-directed optimization support where appropriate and aligned with clinic expectations.
VALUE-BASED ALIGNMENT
TRACKING, DOCUMENTATION, AND VALUE-BASED SUPPORT
Tools, reporting, and follow-through that support patient care and quality performance.
The service model includes QR-code access to HIPAA-compliant forms and tracking workflows, patient and provider visibility into results, and documentation that helps office follow-up stay connected to what happened between visits. It also creates a stronger foundation for care-gap closure, quality metric follow-through, and value-based alignment.
HIPAA-compliant patient tracking tools
Patients can use QR-code access to complete lifestyle tracking, questionnaires, and progress reflections in a way that is simple to revisit between monthly contacts.
TRACKING TOOLS
Results access for patients and providers
The tracking workflow is designed so both patients and providers can view relevant progress information, helping office follow-up stay grounded in what happened between visits.
PROVIDER VIEW
Searchable documentation and reporting support
EchoCarePlus maintains structured, auditable documentation and reporting that support care continuity, billing visibility, and day-to-day clinic communication. The platform tracks clinician activity minute by minute, giving the practice transparent, audit-ready records for chronic care management, CMS requirements, and more detailed provider review when needed.
AUDITABLE RECORDS
CMS PROGRAM EXPANSION
A foundation that can grow into additional CMS-aligned services.
Once the chronic care model is established, practices may choose to expand into other service lines that build on the same operational infrastructure, clinical follow-up, and documentation discipline.
BUILT TO EXPAND OVER TIME
Continued CCM program growth
Remote Physiologic Monitoring (RPM)
Behavioral Health Integration (BHI)
Annual Wellness Visits (AWV)
Transition of Care (TOC)
RECOMMENDED STARTING POINT
Begin with the CCM Discovery Program before expanding services.
The best first step is a 20-minute interview to review workflow fit, patient opportunity, and whether the CCM Discovery Program is the right entry point for your practice.