Connected care between visits

Chronic care management that keeps every month moving

Bring care plans, monthly outreach, staff activity, and program oversight into one focused workspace—so your team can spend less time chasing information and more time helping patients stay on course.

  • Structured care plans
  • Monthly activity tracking
  • Clear team visibility
Care manager and physician reviewing chronic care plans and patient outreach
Care plan ready Goals and barriers organized
Outreach visible Know who needs attention
One coordinated workspace

Turn ongoing care into a clear, repeatable program

Transform your practice with advanced Chronic Care Management (CCM) software and services designed to simplify workflows, improve care coordination, and enhance operational efficiency. Streamline chronic care management, support better patient engagement, and optimize revenue without adding unnecessary administrative burden. Deliver a more connected, patient-centered care experience with powerful tools built for modern healthcare practices.

Keep the care team aligned

Give physicians, care managers, and authorized staff one shared view of patient priorities, recent activity, open barriers, and the next action that is due.

  • Shared care plans with goals and barriers
  • Role-based access for clinical and support staff
  • Handoff notes attached to the patient timeline

Make monthly work visible

Outreach calls, education, medication follow-up, and coordination time are captured as the work happens, so month-end review becomes a quick check.

  • Time and activity logged against each patient
  • Clear view of who still needs contact this month
  • Documentation ready for billing and audit review

Support sustainable growth

A consistent operating model lets your team serve a larger panel without losing oversight or documentation quality as enrollment grows.

  • Repeatable workflow for every enrolled patient
  • Program-level oversight for supervising providers
  • Room to scale enrollment without adding chaos
Patient connected with physician, care manager, pharmacy, and monitoring team
Patient-centered coordination

Connect the people and information around each patient

Chronic care rarely lives in one encounter. ZimalCloud helps the care team bring together the plan, the conversation, and the follow-through needed between visits.

  • A living, practical care plan Keep conditions, goals, interventions, barriers, and responsible team members in one place that stays current as the month unfolds.
  • Meaningful patient engagement Capture outreach, questions, education, and the changes that matter to the patient without losing prior context.
  • Clear handoffs and follow-up Surface open needs early so work can move to the right person quickly, with history and next steps attached.
A practical monthly rhythm

From enrollment to ongoing follow-through

Build a consistent workflow your team can understand, supervise, and improve over time.

  1. STEP 01

    Identify and enroll

    Organize eligible patients, capture consent, and record program participation through a clear intake flow.

  2. STEP 02

    Build the care plan

    Translate clinical priorities into goals, interventions, barriers, and follow-up actions the whole team can see.

  3. STEP 03

    Engage each month

    Guide outreach with the right context and document meaningful patient interaction while it is fresh.

  4. STEP 04

    Coordinate and respond

    Route emerging needs, update the plan, and keep the treating provider informed throughout.

  5. STEP 05

    Review and report

    See activity and time together before completing the monthly documentation cycle.

Built for daily care work

Tools that make the CCM program easier to operate

Keep essential pieces close at hand without rebuilding process from scattered files and generic task lists.

Panel views and prioritization

Filter patients by risk, utilization, last contact, or pending follow-up.

Care plan workspace

Organize problems, goals, interventions, barriers, and progress in one place.

Activity and time records

Capture monthly work with context that supports review and supervision.

Follow-up visibility

Make open actions and patients needing outreach easier to find.

Role-aware collaboration

Support coordinated work across physicians, clinical staff, and care managers.

Program oversight

Review workload, activity patterns, and operational progress across the panel.

Designed around your practice

A strong fit for teams building structured between-visit care

Primary care clinics, accountable care organizations, and specialty practices that manage large panels of patients with chronic illness.

Primary care Multi-specialty groups ACOs and care networks Growing care teams
Ready to simplify monthly care?

See how ZimalCloud can support your CCM program

Tell us about your patient panel, staffing model, and current workflow. We will shape the conversation around how your practice delivers care.