Chronic Care Management
What is Chronic Care Management?
The physician and midlevel provider’s role is to provide patient-centeredness to maintain an ongoing, active partnership with a personal primary care provider, who then leads a team focused on providing a proactive, preventative, and chronic care management plan. This plan should help maintain or improve patients’ functional status, increase their capacity to self-manage their condition, eliminate unnecessary clinical testing, and reduce their need for acute care services by avoiding ER visits and being hospitalized.
Chronic Care Coordination Model:
- Built on evidence-based practice.
- Promotes patient self-management.
- Relies on partnership with patients, family, and caregivers.
- Care Coordinator uses health coaching strategies.
- Engagement with relevant and existing community resources.
What We Do:
- Improve the patient’s quality of life due to better management of chronic health conditions.
- Share decision-making, involving both patients and families.
- Avoid service duplication thus preventing harm.
- Advocate for and support during disease progression.
- Assistance with advanced care planning.
Candidates:
- Patients with two or more chronic diseases.
- Frequent use of high-cost services such as ER and hospital readmissions.
- Compliance challenges to their medical plan for primary and secondary care follow-up.
