Chronic Care Management

Currently provided for our Medicare B patients

The Chronic Care Management Program (CCM) has been designed to improve the coordination of your health care and create a team for you that focuses on your unique health care needs. The nurses in the program aim to create a stronger relationship with you by supporting, counseling and assisting in decisions regarding your health and health care. When a patient is faced with multiple (two or more) chronic conditions for an extended period of time they are often subject to countless medical office visits, frequent visits to urgent care/emergency centers, and a lengthy list of medications necessary to treat each condition.

The CCM program is able to assist in counseling each patient and the members of their care team by developing a Patient-Centered Care Plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment. CCM also ensures plentiful access to care; especially opportunities for the patient/caregiver to communicate with their practitioners, and managing patient care services as a systematic assessment of their patient’s medical, functional, and psychosocial needs.

Examples for Chronic Condition include (but not limited to);

• Alzheimer’s Disease & Related Dementia
• Arthritis (Osteo & Rheumatoid)
• Asthma
• Atrial Fibrillation
• Cancer
• Chronic Obstructive Pulmonary Disease
• Diabetes
• Heart Failure
• Hypertension

A Comprehensive Care Plan for all health issues typically includes, but is not limited to, the following elements:

• Problem list; (list of diagnosed chronic diseases)
• Expected outcome and prognosis
• Measurable treatment goals
• Symptom management
• Planned interventions and identification of all the individuals responsible for each intervention
• Medication management
• Community/Social services ordered
• A description of how services of agencies and specialists outside the practice will be directed/coordinated
• Schedule for periodic review and, when applicable, revision of the care plan