At Infocus Solutions, our Chronic Care Management (CCM) service goes above and beyond to ensure that your patients receive top-tier healthcare support. Our extensive range of CCM services encompasses the structured recording of patient health information, the creation and maintenance of comprehensive electronic care plans, expertly managing transitions of care, and providing other crucial care management services. We are dedicated to coordinating and promptly sharing patient health information both within and outside the practice, fostering a seamless healthcare experience for all.


Our CCM services are designed to be patient-centric and are primarily delivered outside of traditional face-to-face visits. We adhere to the principles of advanced primary care, offering patients:

  1. Continuity of Care: Patients benefit from an ongoing relationship with a dedicated member of our care team, ensuring consistent support and guidance.
  2. Chronic Disease Management: We empower patients to work towards their health goals, particularly in managing chronic conditions, through personalized care plans.
  3. Round-the-Clock Access: Patients have 24/7 access to care and health information, ensuring they receive the assistance they need when they need it most.
  4. Preventive Care: We emphasize the importance of preventive care, helping patients stay on top of their health and wellness.
  5. Engagement: We actively engage patients and caregivers in their healthcare journey, promoting active participation and informed decision-making.
  6. Efficient Health Information Sharing: Timely and effective sharing of health information is a cornerstone of our CCM service.

Our CCM services break down into key components:

Structured Recording of Patient Health Information: We meticulously record patient demographics, health problems, medications, and medication allergies using certified Electronic Health Record (EHR) technology. Our EHR system meets the requirements of the EHR Incentive Programs, ensuring compliance and reliability. For more details, please visit CMS Website.(

Comprehensive Care Plans: Our patient-centered electronic care plans are based on a holistic assessment of physical, mental, cognitive, psychosocial, functional, and environmental factors. These comprehensive care plans address all health concerns, with a specific focus on effectively managing chronic conditions. We provide patients and caregivers with copies of these care plans, and we ensure that they are readily available and shared promptly with all individuals involved in the patient's care. A wealth of care planning tools and resources are also available through various organizations.

Our comprehensive care plans encompass the following elements:

  1. Problem List: Identifying and categorizing health issues.
  2. Expected Outcomes and Prognosis: Defining the desired results and the outlook.
  3. Measurable Treatment Goals: Setting clear objectives.
  4. Symptom Management: Strategies for addressing symptoms.
  5. Planned Interventions: Identifying responsible parties for each intervention.
  6. Medication Management: Ensuring proper medication use.
  7. Community/Social Services: Ordering necessary services.
  8. Coordination of External Services: Detailing how services from external agencies and specialists will be directed and coordinated.
  9. Scheduled Review: Establishing periodic review and, when needed, revision of the care plan.

At Infocus Solutions, we are committed to providing comprehensive, patient-focused Chronic Care Management services that make a positive impact on the health and well-being of your patients.