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Chronic Care Management for Medicare Patients

Chronic Care Management

Attention Medicare Patients

Medicare patients with multiple chronic conditions qualify for additional support to manage their overall wellness. As part of the program, patients receive:

  1. Around the clock (24/7) access to the care team from the doctor’s office.
  2. Creation of a personalized care plan for all their health conditions.
  3. Monitoring of medications and treatment plan.
  4. Coordination for preventive services or visits required based on a personal assessment and care plan.

Chronic Care Management

You are entitled to additional benefits to help manage your chronic conditions. 

Benefits to our Medicare Patients include:

-Chart review in advance of every visit to identify issues that should be discussed and addressed.

-Follow-up after each visit to make sure you are feeling well and your medications are working.

-Coordinated care between specialists, testing centers, and hospitals to make sure everyone is working together.

-More personalized attention to you and your health management goals.

Comprehensive Care Plan

A comprehensive care plan for all health issues typically includes, but is not limited to, the following elements:

  • Problem list;
  • Expected outcome and prognosis;
  • Measurable treatment goals;
  • Symptom management;
  • Planned interventions and identification of 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; and
  • Schedule for periodic review and, when applicable, revision of the care plan.
Access to Care
  • Ensure 24-hour-a-day, 7-day-a-week (24/7) access to care management services, providing the patient with a means to make timely contact with health care practitioners in the practice who have access to the patient’s electronic care plan to address his or her urgent chronic care needs.
  • Ensure continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.
  • Provide enhanced opportunities for the patient and any caregiver to communicate with the practitioner regarding the patient’s care. Do this through telephone, secure messaging, secure Internet, or other asynchronous non-face-to-face consultation methods, in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

With the CCM Program your doctor is able to spend more time on your care, even when you aren’t in the office.

There is little to no cost to join the program, so ask about CCM today! 


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