Chronic Care Management

Monthly CCM Metrics

Upload your monthly CSV export and get an instant snapshot of outreach, care plan progress, clinical outcomes, and team performance.

Month
Tip: Use the starter file ccm_template.csv as your monthly export format.

Executive Summary

One-screen snapshot of the month

Contact Rate

0%

0/0 connected

Care Plans Discussed

0

0% of connected

Active Scheduled Follow-up

0

0% of connected

Top Disease

--

0 patients

Top Follow-up Age

--

0 follow-ups

Care Plan Pipeline

    Engagement Funnel

      Care Plan Discussed (Rate)

      Care Plan Created / Sent / Discussed

      Care Plan Pipeline

      Created → Sent → Discussed → Follow-up needed

      Engagement Funnel

      Attempted → Connected via Call → Discussed

      Clinical Outcomes

      Symptoms, refills, follow-ups, RPM, and hospitalizations

      Primary Disease

      Counts of primary disease reported this month

      Disease Status

      Improving, stable, worsening, or unknown

      Improving Symptoms reduced OR adherence improved AND no related ER/hospitalization.
      Stable No meaningful change in symptoms or adherence.
      Worsening Symptoms worse OR related ER/hospitalization.
      Unknown Not assessed this month.

      Disease Mix & Improvement

      Pie charts for primary disease mix and patient improvement status

      Commonly Managed Diseases

      Patient Improvement

      Call Receptiveness

      Connected via call vs engaged vs not connected

      Connected Outcomes

      Rates among patients successfully connected

      Care Gap Closure

      Closure rate among connected patients

      Age & Gender Insights

      Age groups with primary conditions, active follow-ups, and call receptiveness

      Primary Disease by Age Group

      Active Follow-up by Age Group

      Receptiveness by Age Group

      Disease Status by Primary Disease

      Improving, stable, worsening, and unknown counts by condition

      Agent Performance

      Calls, reach rate, care plan discussions, active scheduled follow-up, and notes

      Verbatim Concerns

      Filter by category and urgency

      Patient Concerns Lookup

      Select a patient ID to view verbatim concerns

      Caller Productivity

      Connected, care plan discussed, active scheduled appointments, and earlier bookings per agent