46 million Medicare beneficiaries live with two or more chronic conditions. Fewer than 6% are enrolled in chronic care management, and even they go invisible between calls.
Medicare beneficiaries live with two or more chronic conditions
are actively enrolled in a CCM program today
the standard CCM contact: a phone call, once a month
can pass before a care team notices a decline
The gap between visits
is where patients drift.
A lightweight check-in layer that runs between appointments, designed to fit inside the team you already have.
Easy implementation
No IT project. Live in days.
Automated check-ins
App-based check-ins where patients enter symptoms, vitals, and changes between visits.
Data consolidated, trends surfaced
Drifting patients get filtered against thresholds and prioritized for near real time review.
Care team dashboard
Who to call, who’s stable, and why — every morning.
Clinical engagement, reclaimed
Less box-checking. More meaningful call time. CCM that scales.
Documentation that is defensible
Billing-ready records, without entering the revenue cycle.
What this looks like for the care team.
Here’s what changes day to day.
Care teams carry more than they can manually reach.
- Panels too large to reach between visits
- No clear view of who’s stable and who isn’t
- Five-plus hours in the EHR for every eight with patients
- ER visits they can’t see coming
Prioritized
A clearly organized daily panel: Elect who to call, who’s stable, and why.
Efficient
Check-ins sent automatically between visits. Routine manual outreach minimized.
Documented
Progress notes drafted from each interaction, with the clinician signing off.
Proactive
Emerging trends made visible so care teams can act earlier.
How it fits
with your EHR.
Aetonix’s platform is built to complement your EHR. Multiple integration pathways, up to bidirectional data exchange, let us match the lift to what your team can absorb.
- Lightest lift
One-way feed
We read from your EHR (demographics, problems, medications) to seed each patient record.
- Common
Scheduled sync
Updates exchanged in both directions on a set cadence, with no live connection to maintain.
- Deepest
Bidirectional exchange
Live read and write-back: check-in results and signed notes flow straight into the chart.
Built for FQHCs, hospitals, health systems, and ACOs.
If you’re working through this gap too, let’s compare notes.
Walk us through your CCM program. We’ll show you what we’re seeing across partner programs.