Principal Care Management (PCM) is care coordination similar to CCM. Services are conducted outside of the physicians' office and are non-face-to-face, however they are provided to patients that have at least 1 (one) chronic condition and will last between 3 months and 1 year.
The ChronWell PCM program includes the development of a specialists' approved care plan with monthly communication to patients and other treating health professionals for patients with at least 1 chronic condition. 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.