top of page

Chronic Care Management 

A Helping Hand Between Office Visits

We know managing all your care needs, from routine health maintenance to advice from specialists and changes in medications can be complicated, but it doesn’t have to be.

Chronic Care Management (CCM) is a new program available to Medicare patients living with more than one chronic condition, such as arthritis, diabetes, depression, or high blood pressure.

Care Coordination

We now offer a service that can help you navigate these challenges. You will benefit by receiving monthly telephone assistance in between your regular appointments. This includes one of our offie team members to guide you towards better health.

Chronic Care Management extends your care outside of the four walls of your physician's practice to ensure that you maintain the best possible health. Each month your Care Coordinator will call you to:

  • Assist with scheduling appointments, lab tests or other tests

  • Explain how and when to take your medications

  • Coordinate any home health or medical equipment needs

  • Connect you with health education resources, services and programs

  • Identify available community resources

  • Coordinate follow-up care after leaving the hospital

  • Access other support services you need to stay well

We always offer 24/7 assistance for urgent matters outside our office hours. 

Cost and Coverage

This service is covered by Medicare and Medicare Advantage Plans. We can determine if you qualify and will be covered. 

While you can only sign up for Chronic Care Management services, you are able to opt out any time—there are no strings attached.

Contact Us to see if you are a good candidate for CCM!

If you have questions about this service and would like to learn more on this program, or how to enroll, please fill out this form and we can see if you qualify. 

What is Chronic Care Management?

Chronic Care Management is a care coordination program designed by Medicare to help patients better manage their chronic conditions. It was designed to give you greater support and access to care between office visits, even while at home.

What is a chronic condition?

A chronic condition is an ongoing, long-lasting health condition, which will require continual management and treatment. Left untreated, a chronic condition can hinder independence and negatively impact health. A few examples of chronic conditions include asthma, diabetes, arthritis, hypertension, and heart disease.

What is care coordination?

Care Coordination is the deliberate organization of patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. Care Coordination services (like those that are part of Medicare’s Chronic Care Management program) provide extra layers of support and care between doctor visits to eligible patients who have two or more chronic conditions.

Who is eligible?

To be eligible for the Chronic Care Management program you must be a Medicare beneficiary and have multiple (two or more) chronic conditions expected to last at least 12 months, or until end of life. If you are unsure if your conditions qualify contact your primary care provider and they will be able to assist you further.

Why does my doctor want this for me?

Managing and coordinating care can be especially difficult if you suffer from multiple chronic conditions. You may be seeing different types of doctors or taking several medications. For every medication you take, it’s important to know how it reacts with other medications. For every doctor you see, there are test results or health information that needs to be shared. When your care is coordinated properly, your doctors get the information they need when they need it.

But what if I feel fine?

One of the great benefits of Chronic Care Management is not only to help you achieve good health, but also to maintain it. That’s why the program also focuses on things like helping you keep on top of preventive care and helping you locate specialists, valuable healthcare resources, and community services.

Why should I enroll?

Chronic Care Management extends your care outside of the four walls of your physician's practice to help you maintain the best possible health. A treatment plan (care pathway) will be created to plan for your ongoing care and better address all your health related issues. Your care coordinator will be there for you helping you navigate the healthcare system, including scheduling appointments, helping with refills, and answering lingering questions. Your care coordinator acts as an extension of your doctor and helps your doctor monitor and adjust your care accordingly.

How do I opt-out of the program?

With Chronic Care Management, there is no long-term commitment. You may opt-out any time by notifying us via phone/message/email. After filling out a form, you will be un-enrolled at the end of the current month.

bottom of page