Chronic Care Management

What is Chronic Care Management?
The physician and midlevel’s role is to provide patient centeredness to maintain an ongoing, active partnership with a personal primary care provider who leads a team to provide a proactive, preventative, and chronic care management plan.

To maintain or improve patients’ functional status, increase their capacity to self-manage their condition, eliminate unnecessary clinical testing, and reduce need for acute care services either through avoiding an ER visit or 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 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


· Patients with two or more chronic diseases
· Frequent use of high cost services such as ER and hospital readmissions
· Compliance challenges to medical plan of care and primary care follow-up

For more information, contact the Heart of America Johnson Clinic in Rugby at 776.5235.