Chronic Care Management

Qualifications for the Chronic Care Management program (CCM)

Individual needs to have two or more chronic conditions which are expected to last 12 months or longer, places the individual at significant risk for death, acute exacerbation, decompensation, or functional decline. 

            Individual needs to have seen a provider within the last year of enrolling in Chronic Care services.

Benefits of Chronic Care Management

In addition to office visits and other face-to-face encounters, CCM services include:

  • Open lines of communication with patient care manager and other health professionals for care coordination
  • Access to healthcare team 24/7.
  • Care plan is established that addresses physical, mental, cognitive, psychosocial, functional and environmental needs for the individual.
  • Assists with scheduling timely appointments for all recommended preventative care services
  • Medication reconciliation and oversight of medication management.

Diabetic patients that have been enrolled in CCM have lowered their Hgb A1C by becoming more compliant with diet, medications, and following up lab tests.

It worked for this patient…

A patient diagnosed with Congestive Heart Failure was contacted by phone as part of routine Chronic Care follow up. The patient was experiencing shortness of breath over the phone.  The care manager spoke with the patient’s physician and scheduled the patient to come in the clinic.  The Primary care physician evaluated the patient and discovered that diuretic medication had run out. The physician adjusted the medication dose to prevent running out again. The physician also confirmed that no other immediate health issues needed urgent treatment.  This interaction prevented the patient from an Emergency Room visit and possible inpatient hospital stay.