Chronic Care Management (CCM) is an innovative healthcare service designed to help patients with chronic conditions manage their health more effectively. CCM provides comprehensive, evidence-based care for patients with chronic conditions. This care includes: - Comprehensive assessments of each patient’s health and medical history - Creation of customized treatment plans tailored to each patient’s specific needs - Regular follow-up visits to review progress and adjust the treatment plan - Helping patients understand their chronic condition, the goals of treatment, and the importance of following their treatment plan - Education on lifestyle changes that can help improve the patient’s health - Working with the patient’s healthcare team to coordinate care Chronic Care Management is an essential part of maintaining a healthy lifestyle for people with chronic conditions. By working with a CCM provider, patients can better understand their condition, set goals for managing it, and receive the necessary support and resources to remain healthy.

Chronic Care Management services typically include

1. Comprehensive care planning, coordination, and health coaching

2. Access to care coordination and health education resources

3. Monitoring and management of chronic conditions

4. Medication management

5. Assistance with goal setting and self-management

6. Coordination with other healthcare providers

7. Connecting patients to community resources

8. Communication with family caregivers and other support systems

9. Development of a care plan to address patient needs.

Chronic Care Management (CCM) is available to Medicare beneficiaries with two or more chronic conditions, such as diabetes, congestive heart failure, COPD, depression, or arthritis. To be eligible, the patient must have multiple chronic conditions that require ongoing care and management.

The frequency of your meetings with your Chronic Care Management care team will depend on your individual needs and circumstances. Generally, care teams meet with patients on a weekly or monthly basis. Still, you may also have more frequent meetings depending on your health needs.

There are a wide range of services that can be provided under CCM for Medicare beneficiaries with multiple chronic conditions. While the list below is not exhaustive, it provides examples of the types of services that can be provided:

Care management and transitional care management services

Communicating with the Medicare beneficiary in person, by phone, or electronically for care coordination

Community resource referral and linkage

Coordinating community and social support services

Disease self-management education and support

Health coaching

Health education, including health literacy

Interventions to reduce falls or risk factors for falls

Medication management

Preventive health counseling

Symptom management

The benefit of participating in Chronic Care Management (CCM) is that it allows patients to receive better care coordination and management of their chronic conditions. It also enables healthcare providers to work together to create individualized treatment plans. Through CCM, patients can receive improved access to care, more comprehensive education, better coordination between providers, and better overall health outcomes

Your provider will be available for follow-up visits and phone calls to discuss your progress, answer any questions, and provide additional support. They may also refer you to other in-house specialists at SC House Calls if needed. Additionally, your provider may suggest lifestyle changes, such as exercise and nutrition modifications, to help improve your health.

Medicare and Medicaid provide Chronic Care Managementresources for pateints. The cost to the patient is your co-pay.

It depends on the type of insurance coverage you have. If you have Medicare, then Chronic Care Management may be covered. Contact your insurance provider for more information about your specific plan.