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Chronic Care Management Software

Run chronic care management in-house with AI

Cynnvi lets your existing care team operate Chronic Care Management end to end, while AI reduces the outreach, documentation, task-management, and time-capture work that normally eats up a coordinator's day.

Built for independent primary care clinics running CCM with their own staff, not an outsourced call center.

CYNNVI

Today's Care Work

Maria Johnson

In EHR session · time captured automatically

9:24

Tasks for this month

Review home blood pressure readings
Discuss medication adherence
Confirm nephrology referral status

Captured automatically

Encounter viewed10:58 AM – 11:00 AM
Encounter viewed11:00 AM – 11:01 AM
Referrals viewed11:02 AM – 11:03 AM
Inside Cynnvi

What your care team sees each day

Included voice outreach, AI-drafted documentation, and the patient-specific follow-up task, all connected to the same worklist.

Included AI voice outreach

AI outreach

Patient answered

Patient available

“Maria is available to speak now.”

Warm transfer

Nurse accepted · time capture started

Accept call

Time capture

6 minutes logged automatically

Documentation

AI Scribe note ready for review

AI Scribe documentation

Maria Johnson

Call 6:12

AI Scribe

Drafted after the call · Pending staff review

Discussed nephrology referral and medication adherence. Patient reports improved home BP readings and no dizziness. Confirmed lisinopril refill. Plan: continue weekly BP log, nephrology follow-up in 6 months.

Suggested billing detail

CPT 99490Time logged: 22 minCare-plan goal updated

Suggested next step

Schedule the nephrology follow-up in 6 months and add it to the care plan.

Ready to write back to the EHREdit

Patient-specific follow-up task

AI-generated suggestion. Human review required.

Follow up on home blood pressure readings

Reason: The last office note requested a two-week blood pressure log.

Care-plan goal: Maintain average blood pressure below the clinician-defined target.

Choose which actions to take

  • Send SMS blood pressure check-inSchedules AI text outreach asking the patient for this week's home readings.
  • Discuss medication adherenceAdds to the task list along with the AI-generated clinical summary of the BP conversation.
  • Send voice AI to schedule care management callTriggers an AI voice call to schedule the patient's monthly care management check-in.
Office note, July 18 · Hypertension care plan, version 3
Approve all (3)Edit

How Cynnvi runs CCM, month to month

Every step feeds the next, from identifying eligible patients to preparing the monthly billing record.

1

Identify and enroll

Cynnvi surfaces patients with two or more qualifying chronic conditions, then AI voice outreach handles enrollment calls and captures consent.

2

Generate the care plan and tasks

A patient-specific care plan is drafted from the chart, then turned into a prioritized monthly task list for staff to review and approve.

3

Reach patients

Included AI voice outreach calls patients on the worklist, warm-transfers anyone available to speak, and schedules the rest for a staff call.

4

Capture human work and time

Every minute of clinical staff time is captured automatically from real EHR activity and traced back to the specific note, order, or referral behind it.

5

Draft documentation

As soon as a staff call ends, the AI Scribe drafts the clinical note. Staff confirm it, then it's written back to the chart.

6

Prepare the monthly billing record

Approved time, documentation, and consent are assembled into a monthly billing record with a suggested CCM code, ready for staff sign-off.

Why clinics choose Cynnvi over a CCM vendor or outsourced platform

EHR-embedded workflow

Cynnvi opens from the patient's chart in the EHR your clinic already uses. No separate portal, no new login.

Automatic, traceable time capture

Time is captured from real chart activity and traces back to the note, order, or referral behind it, not a manual stopwatch.

AI Scribe on staff calls

Every staff care-management call ends with a drafted note, ready to review and write back to the chart.

Patient-specific tasks

Tasks come from the approved care plan, recent notes, and each call, with the source shown for every suggestion.

Included AI voice outreach

AI voice outreach to help reach and enroll patients is included, not billed as a separate line item.

Clinic-operated, not outsourced

Your own staff run CCM with Cynnvi's help. The program isn't handed off to a third-party call center.

No per-patient fee

One flat monthly price per clinic covers the program, regardless of how many patients are enrolled.

yourehr.com/patients/mjohnson87

Maria Johnson

DOB 03/14/1964 · MRN 83347583

Encounters

Problem list

Medications

Referrals

Maria Johnson

9:24

Tasks for this month

Review home blood pressure readings
Discuss medication adherence
Confirm nephrology referral status

Phone call

AI talking

Step 1 · Attest this is billable time

I attest this time reflects clinically necessary care management work performed by me.
Supported EHRs

Works inside the EHR your clinic already uses

No separate portal, no new login. Cynnvi opens from the patient's chart.

See all integrations

Simple, predictable pricing

$179 per clinic per month. No per-patient fee, no implementation fee, no enrollment fee.

Built for audit-ready compliance, with a human always in the loop

  • Every AI-drafted note, task, and time entry is reviewed and approved by clinical staff before it counts toward billing, nothing is submitted automatically.
  • Time capture traces back to the specific chart activity (note, order, or referral) behind it, producing an audit trail instead of a self-reported estimate.
  • Staff attest to the accuracy of captured time and documentation before it's included in the monthly billing record.
  • A signed Business Associate Agreement (BAA) is included, covering how protected health information is handled.

Frequently asked questions

Is this a CCM platform we manage ourselves, or an outsourced CCM vendor?

Cynnvi is software your own clinical staff use, not an outsourced CCM vendor or call center. Your team enrolls patients, reviews AI-drafted work, and stays the clinical decision-maker throughout.

Do we need a separate login or portal?

No. Cynnvi opens from inside the patient's chart in the EHR you already use, so staff don't need to switch between systems to run CCM.

Is there a per-patient fee?

No. Cynnvi is priced per clinic per month, not per enrolled patient, so growing your CCM panel doesn't change the price.

How does time capture work, and can we trust it for billing?

Time is captured automatically from real EHR activity (chart views, orders, referrals) and call duration, with every entry traceable to the specific action behind it. Staff review and approve captured time before it's used in the monthly billing record.

Does the AI replace our care coordinators?

No. AI drafts documentation, suggests tasks, and handles voice outreach, but staff review and approve everything before it's finalized. The goal is less write-up and outreach work for your existing team, not fewer staff.

Which EHRs does this work with?

Cynnvi supports Athenahealth, Aprima, DrChrono, eClinicalWorks, Elation, MDland, NextGen Enterprise, Office Ally EHR 24/7, Practice Fusion, and TouchWorks. See our integrations page for details on your EHR.

How is this different from generic CCM software or a billing platform?

Many CCM platforms track time and documentation manually. Cynnvi automates the outreach, documentation, task generation, and time capture around that workflow, so staff spend less time on data entry and more time on patient care.