Chronic Care Management (CCM) is care coordination that is outside of the physicians office and is non-face-to-face services provided to patients that have at least 2 (two) chronic conditions.
The ChronWell CCM program includes the development of a physician approved care plan with monthly communication to patients and other treating health professionals for patients with 2 or more chronic conditions. The Chronic Care Manager (MD, PA, NP) will work with patients remotely and will include:
The designated Care Manager establishes, implements, revises, monitors and manages an electronic care plan that addresses the physical, mental, cognitive, psychosocial, functional, and environmental needs of the patient as well as maintains an inventory of resources and support that the patient needs. Chronic care management is an extension of the care delivered by the clinician at the point of care and provides 24/7 access to a clinician. The patient will receive the care plan and updates monthly.