Chronic Care Management

Why is Chronic Care Management Important?

There are an estimated 117 million adults that have one or more chronic health conditions, and one in four adults have two or more chronic health conditions. We can help!

Between doctor visits, taking the right medications at the right times, and following advice from different health care professionals, managing chronic conditions like diabetes, arthritis or depression can be overwhelming.

If you have Medicare, ask your doctor about chronic care management (CCM) services to get connected care, so you can spend less time managing your care and more time doing what you love.

Chronic care management services may include:

• Unlimited time each month for CCM services
• Personalized assistance from a dedicated health care professional who will work with you to create a care plan
• Coordination of care between your pharmacy, specialists, testing centers, hospitals, and more
• 24/7 emergency access to a health care professional
• Expert assistance with setting and meeting your health goals
• Intake by social work case management and medical and/or mental health provider in collaboration with Primary Care Provider to determine areas of unmet need
• Interdisciplinary team (IDT) approach to in-home care with referral as appropriate for Home Healthcare, Physical Therapy, Occupational Therapy, Nursing, CNA, etc.
• Connection to community supports and services, such as home-delivered meals, durable medical equipment, and Community Choices Waiver services
• Mental Health
• In-home remote blood pressure, and weight monitoring
• LIV More services including cooking, cleaning, transportation to and from medical appointments, errands
• IDT team meets monthly and provides progress report to PCP