Chronic Care Management Program
Chronic Care Management is a team-based care coordination program designed by Medicare to help patients and their support team manage their chronic medical conditions more effectively. It is designed to give more support and access to care between office visits.
The goal of the Chronic Care Management program is to get and keep patients healthy, keep patients out of the hospital, and to minimize costs and inconvenience due to unnecessary visits to doctors, emergency rooms, labs, or hospitals.
A Care Coordinator will meet with you in person or over the phone to discuss your health, and what has been going well, or maybe what has not.
Who Should Participate in the Chronic Care Management Program?
The Chronic Care Management program is recommended for patients who see more than one healthcare provider and have two or more chronic conditions, such as:
- Alzheimer’s disease and related dementia
- Asthma
- Cancer
- Chronic kidney disease
- Chronic obstructive pulmonary disease (COPD)
- Depression
- Diabetes
- Heart failure
- High blood pressure
Benefits of the Chronic Care Management Program
Everyone benefits from coordinated, patient-centered care. However, Chronic Care Management is especially important for people with chronic or complex conditions. In this program, you receive:
- Creation of a Personalized Care Plan with goals, accountability, and encouragement
- Coordination of care between your primary care provider, specialists, pharmacy, testing centers, hospitals, and more
- Assistance scheduling appointments and requesting prescription refills
- Explain how and when to take medications
- Phone check-ins between visits to help keep you on track
- Better communication with your healthcare team
- Reminders of necessary preventive screenings, upcoming appointments, and tests
- Education to help you understand and manage your health conditions
- Referrals for medical or community services to help improve your quality of life
Studies have shown that people who participate in Chronic Care Management have fewer hospitalizations, and reduced costs of care.
Program Fees
There is a fee for this service. Many insurance companies provide coverage for Chronic Care Management services, but we recommend checking with your insurance provider to verify coverage and out-of-pocket costs. You are able to opt out at any time. If you are concerned about your ability to pay, please contact our Business Services office to discuss financial assistance options: 320-864-7101
Contact and How to Enroll
Please call 320-864-3121 ext. 1444 between 8:00 am and 4:30 pm, Monday through Friday, to speak with a Care Coordinator.
After Hours Contact
For urgent needs after hours, please call our main line at 320-864-3121 and identify yourself as a Chronic Care Management patient. You will be routed to a nurse for assistance.
