Chronic Care Management (CCM)
What is Chronic Care Management (CCM)?
Chronic care management (CCM) is the oversight and education of a patient diagnoses with two or more chronic health conditions.
CCM services include outside clinic encounters focused on advanced primary care by:
- Fostering therapeutic patient relationships with chosen care team member
- Supporting patients with chronic diseases in achieving health goals
- 24/7 patient access to care and health information
- Preventive care
- Patient education
- Prompt referrals
Examples of chronic conditions include, but are not limited to:
- Alzheimer’s disease and related dementia
- Arthritis (Osteoarthritis and rheumatoid)
- Asthma
- Atrial fibrillation
- Autism spectrum disorders
- Cancer
- Cardiovascular disease
- Chronic Obstructive Pulmonary Disease (COPD)
- Depression
- Diabetes
- Hypertension
- Infectious diseases (HIV and AIDS)
Comprehensive Care Management
- Require patients have 2 or more chronic conditions
- expected to last 12 months or until their death.
- Require 20 minutes before billing.
- Began with assessing the patient’s medical, functional, and psychosocial needs.
- Patients should receive timely recommended preventive services.
- Review medications and any potential interactions
- Oversee the patient’s medication self-management.
- Coordinate care with home- and community-based clinical service providers
- Manage care transitions between and among health care providers and settings including referrals to other clinicians, or follow-up after an emergency department visit or after discharges from hospitals, skilled nursing facilities, or other health care facilities.
- Create and exchange or share continuity of care documents promptly with other practitioners Concurrent Billing
Our Team of Experienced Clinicians and Providers Works Closely with Patients to Manage Chronic Conditions.
Our team at RPMCCM is dedicated to helping patients successfully manage their chronic conditions. Our experienced clinicians and providers work closely with patients to develop personalized care plans and provide support between doctor visits.
Why Choose RPMCCM
Our Chronic Care Management program has helped patients see a noticeable improvement in their healthcare outcomes, saving them significant costs in the process.
With a high satisfaction rate among our clients, we are confident that our services make a difference in the lives of patients with chronic conditions.
By providing comprehensive care between visits, we are able to better manage chronic conditions and improve outcomes for patients while reducing healthcare costs for them and their caregivers.
Empower Your Healthcare Services
Ready to upgrade your patient care? Contact us today for a consultation!