Chronic Care Management · Decatur, AL

Chronic care, or CCM is care coordination that is outside of the regular office visit for patients with multiple (two or more) chronic conditions expected to last at least 12 months, until the death of the patient, and that place the patient at significant risk of death, acute exacerbation or decompensation or functional decline. This service is a non-face to face encounter that typically occurs over the telephone. This service can be delivered with patients with many conditions such as Diabetes Mellitus, Hypertension, COPD, high cholesterol, and more.

Chronic care is important! Between doctor visits, taking the right medications at the correct times, and following advice from different health care professionals, managing chronic conditions like diabetes, or arthritis can be overwhelming. Chronic care (CCM) is a service to get connected care, so you can spend less time managing your care and more time doing what you love.

Services, such as monthly check-ins and ready access to the patients care team, improve patient care coordination, including improved communication and management of care transitions, referrals, and follow- ups. Chronic care services will help support disease control and health management goals. This includes physical, mental, cognitive, psychosocial, functional, and environmental factors. Patients may also receive a list of resources and community services. Additionally, patients may be encouraged to keep track of referrals, community support and educational information. Care plans can also help caregivers who are furnishing unpaid care.

Chronic care management services may include:

• Twenty minutes of chronic care services
• Personalized assisted from dedicated health care professional who will work with you to create a care plan
• Coordination of care between your pharmacy, specialist, testing centers, hospitals and more.
• Assistance with setting and meeting your personal health care goals.

Chronic care management services are critical components of primary care that promote better health and reduce overall health care costs. Chronic care management is a great resource to help patients improve satisfaction in care and to decrease hospitalizations and emergency room visits. With this program you will get the care you need in between regular scheduled appointments. We know your time and health is valuable, and our goal is to provide exceptional care!