Solutions for Chronic Care Management
Continuous Care Between Every Visit
All-in-one EHR designed for chronic care management programs, primary care teams, and multi-condition practices. From enrollment and consent to monthly care coordination and billing, manage the full CCM lifecycle with tools built for longitudinal care.
Avon understands that chronic care happens between appointments. Our platform combines structured care plans with automated outreach, task management, and time-tracked care coordination — so hypertension, diabetes, COPD, and every comorbidity in between are managed proactively.
With a patient and caregiver portal, integrated labs, eligibility checks, and claims built in, your care managers spend their time on patients. Our platform supports CCM, complex CCM, and hybrid in-person and virtual care models.
The Numbers
- Time Saved per Care Call
- 12 min
- CCM Minutes Captured Automatically
- 100%
- Clean Claims Rate
- 85%
- Implementation Time
- <4 wks
Why Chronic Care Providers Choose Avon
Built for Longitudinal Care
Everything you need to run a chronic care management program, from patient enrollment to monthly billing.
Longitudinal Care Plans
Build structured care plans with problems, goals, and interventions that span every condition a patient carries. Update them at each touchpoint and share them with the whole care team.
One plan per patient, covering hypertension, diabetes, COPD, and every comorbidity together.
CCM Time Tracking & Billing
Track care coordination time automatically and apply it toward monthly CCM billing codes: CPT 99490, 99439, 99487, and 99491.
Know exactly which patients are billable before the month closes.
AI-Powered Documentation
Generate visit notes and check-in call summaries automatically with an AI scribe that understands chronic disease terminology and keeps the longitudinal context across encounters.
Save hours each week while keeping documentation thorough enough for audit.
Labs & Vitals Trending
Order labs and receive results directly in the chart. Track values like A1c and blood pressure over time to spot rising risk early.
Results flow straight into the chart and the patient's care plan.
Between-Visit Engagement
Keep patients on track between appointments with secure messaging, condition education delivered through drip-released Courses, and automations that trigger outreach when something changes.
Caregiver portal included — families of complex patients stay in the loop.
Multi-Condition Billing
Run eligibility checks, submit claims, and generate superbills from the same system that tracks the care — with support for CCM, E/M, and preventive codes billed side by side.
Handle Medicare CCM requirements, consent documentation, and monthly claim cycles with ease.
Core Capabilities
Essential Chronic Care Tools
Comprehensive features designed for care teams managing patients over months and years, not single visits.
Effortless Documentation
AI Notes for Chronic Care Teams
Our AI scribe understands chronic disease management conversations and generates comprehensive documentation automatically. Document office visits, telephone check-ins, and care coordination touchpoints with notes that capture clinical decisions while maintaining your voice.
- Automatic visit and check-in call documentation
- Care plan updates based on encounter findings
- Medication changes and adherence captured in context
Care Plans
Create measurable, condition-spanning care plans with goals, interventions, and target dates. Copy over selected fields from templates and update plans as outcomes evolve.
Task Management
Assign follow-ups, lab reviews, and monthly check-in calls across the care team.
Medication Management
E-prescribe with drug interaction checks and medication reconciliation across the multi-drug regimens that chronic patients actually carry.
Automations
Trigger outreach, tasks, and enrollment steps automatically — when a custom field changes, a peer group changes, or a patient joins a program.
Patient & Caregiver Portals
Give patients and their families secure access to care plans, education, scheduling, and messaging — including in-person and phone-call self-scheduling.
Analytics
See panel-level views of enrollment, billable minutes, and outcomes. Ask questions in plain language with the AI Data Analyst and get answers from your own data.