New eClinicalWorks and healow CCM Specialist Service Expands Chronic Care Access for High-Risk Patients and Reduces Staff Burden

EHR-integrated Chronic Care Management service enables proactive, personalized engagement for high-risk patients—improving adherence, continuity, and long-term outcomes without adding staff

WESTBOROUGH, Mass.--(BUSINESS WIRE)--eClinicalWorks®, one of the largest ambulatory cloud EHRs, introduced the healow Chronic Care Management (CCM) Specialist Service, a new offering through the eClinicalWorks CCM module, designed to help practices improve outcomes for patients with managing chronic conditions through consistent, proactive engagement. By embedding dedicated CCM specialists directly into existing practice workflows, the service enables monthly patient outreach, stronger care continuity, and supports better management of chronic conditions, such as diabetes, hypertension, and cardiovascular disease, while reducing administrative burden on clinical staff.

Chronic conditions require ongoing monitoring and engagement, yet many practices lack the resources to deliver consistent follow-up between visits. As a result, gaps in adherence and communication can lead to complications, hospitalizations, and increased costs. Chronic care management programs like CCM have been shown to improve outcomes—but only when patients receive consistent, ongoing engagement, which this service is designed to deliver at scale.

“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.”

Practices are seeing immediate impact

For practices managing large patient populations with chronic conditions, consistent monthly engagement is key to improving long-term outcomes.

North Alabama Internal Medicine (NAIM), a solo internal medicine practice serving about 50% Medicare patients, adopted the healow CCM Specialist Service, resulting in significant time savings, improved patient engagement, and a more sustainable chronic care program. The practice has expanded its chronic care management without hiring additional staff, while also enhancing continuity of care for its Medicare patients.

“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. “For many of our patients, that call is the most consistent touch point with their care team. For our office, it means we can spend more time with patients here in the office and not on the phone.”

This level of consistent outreach is especially critical for patients managing multiple chronic conditions, where gaps in communication can lead to complications or hospitalizations.

Serving an underserved rural community with limited access to hospitals and specialty care, Fairfield Medical leveraged the CCM Specialist Service to improve consistent, monthly patient outreach. The service enhanced relationships with high-risk patients, nearly 60% of whom qualify for chronic care services, including those managing multiple ongoing conditions needing frequent monitoring and support.

“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 difference in patient trust has been night and day. Care feels more personal, and it’s taken a real weight off our staff."

CCM Specialist as a Service

The healow CCM Specialist Service offloads labor-intensive, non-visit care tasks to certified clinicians who operate directly within the eClinicalWorks EHR, while keeping the practice informed. This model is particularly impactful for patients managing multiple chronic conditions, where consistent monitoring, education, and follow-up directly influence outcomes. These specialists act as an extension of the care team, conducting:

• Structured, monthly outreach to enrolled patients

• Patient record and care plan reviews prior to engagement

• Evidence-based, condition-specific patient care plans to tailor patient engagement

• Real-time EHR documentation of call duration and content

• Proactive alerts to care teams when significant changes or concerns arise

• Billing readiness support and claim initiation

As a result, practices can close care gaps, improve adherence, boost patient engagement, enhance patient and provider satisfaction, and ensure alignment with evidence-based protocols—without placing additional pressure on front office or nursing staff.

Designed for Value-Based Care and Operational Efficiency

• Strengthens patient relationships through personalized outreach: Proactive chronic care management helps practices stay connected with high-risk patients between visits, reinforcing trust, improving continuity of care, and supporting better long-term health outcomes for chronic conditions.

• Extends care team capacity for high-risk and elderly populations: With dedicated support for ongoing outreach, follow-up, and care coordination, practices can better serve patients with complex chronic needs, reduce care gaps, and prevent avoidable escalations, while reducing strain on internal staff.

• Supports scalable, compliant chronic care management programs: A specialized CCM service can help practices grow enrollment, maintain documentation and compliance standards, and deliver consistent, high-quality support that improves disease management outcomes, especially for Medicare populations.

To learn more about how healow CCM Specialist Service can support your practice, visit https://www.eclinicalworks.com/products-services/population-health/chronic-care-management-services/.

About healow

healow is a comprehensive, EHR-agnostic, cloud-based platform for patients, practices, payers, hospitals, and health systems. healow provides Patient Relationship Management, clinical and payer insights, and state-of-the-art interoperability solutions. The PRISMA health information search engine gathers patient records from other EHRs and helps providers focus on the most clinically relevant information at the point of care. healow’s Population Health Management tools, including Remote Patient Monitoring, provide real-time data to deepen understanding of patient populations. And healow Insights automates the bidirectional exchange of data between health plans and providers to improve scores on quality measures, help control costs, and promote better medical outcomes. Learn more at plus.healow.com.

About eClinicalWorks

eClinicalWorks was founded in 1999 to help digitize paper charts for ambulatory practices. Today, eClinicalWorks leads the nation in innovation, offering cloud-based solutions for Electronic Health Records and Practice Management. The company supports ambulatory practices, specialists, health centers, urgent care facilities, and hospital systems to manage their revenue cycle, patient relationships, and Population Health initiatives. A large network of over 180,000 providers and nearly 1 million medical professionals rely upon the power and scalability of the eCW Cloud for its flexible clinical documentation, better front-office workflows, and more efficient billing driven by Robotic Process Automation. By combining innovation, leading-edge technology, and showcasing a strong commitment towards patient safety, eClinicalWorks empowers practices to grow and thrive amid the 21^st-century challenges in healthcare. For more information, visit www.eclinicalworks.com, follow eClinicalWorks on LinkedIn, Facebook, and X/Twitter, or call [phone].