According to CMS (Centers for Medicare and Medicaid), CCM is for patients with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, or functional decline.
Chronic Care Management in Southeast Nebraska
Chronic Care Management
Improving Patient Outcomes
This program is for patients who have two or more chronic conditions which are expected to last more than a year. These conditions can put a patient at great risk for debilitation or even death. Some qualifying illnesses may be diabetes, asthma, COPD, etc.
However, using our chronic care nurse manager, can greatly improve patient outcomes. Having someone to help interpret the why’s of your treatment plan in terms you can understand is beneficial.
Our Chronic Care Management Program
Patients will need to have an office visit with their primary care provider within the last year to be eligible to for this program.
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.
To see if you are eligible, talk to your primary care provider or call our nurse manager, Monica Lechtenberg at 402-245-6609.
Frequently Asked Questions
Medicare allowance will vary geographically. Unadjusted amount is approximately $42 per month. The charges for the CCM services are subject to Medicare’s deductible and coinsurance are the patient responsibility. The deductible and coinsurance cannot be waived.
If enrolled in CCM services, the nurse manager attempts to reach out to each patient monthly. The billed services will be at a minimum of 20 minutes of clinical staff time and can be in-person visits or phone calls, reviewing labs and tests, etc. with the patient.