Chronic Care Management

Chronic Care Management, or CCM, is a new model of care for Medicare patients, designed to improve the coordination of your health care with an emphasis on your overall well-being. Medicare began this program in 2015 recognizing Chronic Care Management is a critical component of medical care that contributes to better health and care for individuals. We believe that to achieve this goal there must be a partnership between you the patient and we as your medical provider. By you remaining involved in the decisions regarding your health, health care and lifestyle, we can develop a stronger relationship with you.

What is Chronic Care Management?

The CCM service is extensive and involves many aspects including a structured recording of your health information, managing a comprehensive electronic care plan, managing transitions of care, coordinating and sharing your health information in a timely manner, support for chronic diseases to achieve health goals, 24/7 patient access to care and health information, receipt of preventive care, and other services that are typically provided outside of face-to-face patient visits.

How Does it Work?

After obtaining your consent to receive CCM services an Initiating Visit is scheduled. During this visit a Structured Recording of your Information Using Certified EHR Technology occurs. This will allow 24/7 Access & Continuity of Care and scheduling of successive appointments. Comprehensive Care Management for the chronic conditions will be initiated with a review and reconciliation of medication along with oversight of your self-management of them. Using our EMR a comprehensive care plan will be developed with particular focus on the chronic conditions being managed. We will be able to share the care plan information electronically and a copy of the chronic care plan will be given to you. There is management and coordination of care transitions between health care providers, facilities, and other services. As a result, there is enhanced communication opportunities for you and any caregiver to communicate with us as your medical provider regarding your care.

Who Qualifies?

If you have Medicare or both Medicare and Medicaid, and have two or more chronic conditions, Medicare is offering CCM services to help you manage your health and spend more time doing the things you enjoy, in good health.

Is Chronic Care Management a Covered Service?

Yes CCM services are covered under Medicare.