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.