Chronic Care Management (CCM-Online)

Structured Chronic Care made as simple as possible; delivering standardised primary care to patients for a range of chronic conditions under the DHB led and funded programme within Counties Manukau District Health Board.

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  • Structured, standardised data collection from Primary to Secondary care systems
  • Enforced eligibility criteria prevents unexpected rejected claims due to ineligibility
  • Multiple modules, include CHF, COPD, CVD, Diabetes, Depression and a general, frequent adult medical admissions module
  • Web based centralised system providing content and interface into Practices
  • Multiple funding streams managed under a single interface
  • Patient enrolment and clinical histories available to Providers from centralised system
  • Integrated into Medtech and MyPractice

CCM Online is the glue between the DHB and Primary Care providers who supply Chronic Care management services within CMDHB.

Benefits of Predict CCM Online (CMDHB)

For Providers

  • Electronic clinical decision support for each chronic condition
  • Multiple funding streams managed under single interface: Careplus, CCM, CVD Annual Review, FAMA
  • Clinical feeds into DHB systems (SDM) possible
  • Patient enrolment and clinical histories available to Providers from the centralised system
  • Features Predict CVD Diabetes as ECDS module for CVD and Diabetes management, integrated with Your Heart Forecast
  • A single interface for all DHB provided Chronic Care funding
  • Integrated into Medtech and MyPractice
  • Standalone version available for other PMS users, this includes the patient population collections and patient histories

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For DHB / PHO

  • Structured and standardised data collection for DHB led programmes
  • Centrally controlled eligibility criteria is enforced, allowing controlled access to DHB funding
  • Modules include: CHF, COPD, CVD, Diabetes, Depression and a general, frequent adult medical admissions (to hospital) module
  • Claiming and transactional information fed back to DHB systems
  • Linkages into DHB databases for contracting tables and patient histories
  • DHB reporting systems’ continuity maintained by passing data payloads back into DHB databases
  • Web based centralised system providing content and interface into Practices
  • Population health reporting made possible through centralised web interface
  • ECDS module creation and management expertise offered as a service (these modules have undergone various clinical updates since the launch of CCM)

Click here for the product brochure.
CCM