Our Chronic Care Manager will create a care plan that is unique to each client. it will address all of the patient's health conditions. We'll identify specific goals, barriers and outcomes to focus on during the program.
Each month, our care manager will call the client to track their progress. If the client has any new concerns or issues, they can be addressed at any time with our care team.
Our care team will provide the patient with a copy of their care plan and clinical summary. The summary will also be shared with other providers involved in the patient's care.

What is Chronic Care Management (CCM)?

Medicare has identified that the care of chronic health condition is a very important goal. Chronic conditions are ongoing medical problems that must be managed effectively in a partnership between the health care team and the patient to maintain the best health possible.

Do I qualify for CCM?

Medicare patients with two or more chronic conditions are eligible for the CCM program. Your doctor will determine if your conditions qualify you.

Examples of common chronic conditions are: Alzheimer's disease and related dementia, asthma, cancer, COPD, depression, diabetes, Ischemic heart disease, hypertension, anemia, hyperlipidemia, stroke, chronic kidney disease, atrial fibrillation, hypothyroidism and osteoporosis.

If you have two or more of these conditions, your doctor will likely encourage you to participate.

We work with a variety of providers to ensure our patients are able to remain safely in their homes and manage their chronic conditions.​We are able to provide the following services through our multidisciplinary care team:

  • Wound Care Nursing
  • Medical Equipment (Home Hospital Beds, Wheelchairs, and Patient Lifts
  • Wound Prevention/Treatment
  • Support Surfaces
  • Negative Pressure Therapy
  • Medical Supplies (Wound Dressings, Incontinence Supplies)
  • Wound Dressings
  • Ostomy Supplies

  • Diabetes Self-Management Tools (Diabetic Testing Strips and Glucometers)
  • Test Strips
  • Diabetic Shoes
  • Pharmacy-Based Medication and Management Services
  • Laboratory Services
  • X-rays
  • Home Health Skilled Nursing Services
  • Home-Based Physical Therapy
  • Home-Based Occupational Therapy
  • Low-Vision Occupational Therapy
  • Counseling and Mental Health Services
  • Medical Nutrition Therapy with a Registered Dietitian
  • Diabetes Self-Management Training
  • Opthalmology Services