eClinicalWorks Launches CCM Specialist Service to Expand Chronic Care Access, Reduce Staff Burden

The service embeds dedicated CCM specialists into existing clinical workflows, enabling structured monthly outreach to patients managing long-term conditions such as diabetes, hypertension, and cardiovascular disease. The model is designed to improve adherence, close care gaps, and ensure consistent monitoring between clinical visits.

“The healow CCM Specialists Service is designed to help practices expand care management programs without overextending staff,” said Dr. Brian Jacobs, VP of Clinical Informatics and International Products at eClinicalWorks. “Having a dedicated resource to conduct monthly outreach to patients on behalf of the practice helps reduce burden on the nursing staff, strengthen patient relationships, and ensure patients with chronic conditions receive consistent monitoring and support between visits.”

Chronic conditions require continuous engagement, but many healthcare practices face resource constraints that limit follow-up care. The CCM Specialist Service addresses this gap by assigning trained clinicians to conduct regular patient check-ins, review care plans, and document interactions directly within the EHR system.

Early adopters have reported operational impact. North Alabama Internal Medicine, a solo practice with a high proportion of Medicare patients, used the service to expand its chronic care program without hiring additional staff.

“Patient calls to our office are down approximately 30%. Our patients are getting consistent monthly check-ins. They have someone who follows up on their prescriptions, assists them with getting prompt refills, checks on their progress, and answers their questions,” said Kellie Terry, office manager at North Alabama Internal Medicine.

Similarly, Fairfield Medical implemented the service to improve outreach to high-risk patients in a rural setting.

“Before implementing the CCM specialist program, our patients were getting calls from a different person every time — and you could feel the disconnect. Now, they have one dedicated specialist who knows them, follows up consistently, and actually feels like part of our team,” said Sarah Lewis, billing manager at Fairfield Medical.

The service operates within the eClinicalWorks EHR, supporting documentation, care coordination, and billing workflows while enabling practices to scale chronic care management without adding staff.