Patients should expect ChronWell to provide a dedicated care manager who will provide professional clinical coordination through consistent and frequent remote communication. Our team is highly trained in providing systematic assessment of the patient’s medical, functional, and psychosocial needs. Our team will use technology based approaches to ensure education, goal setting, and self-management of their chronic condition(s).
The ChronWell team will develop personalized goals that are mutually agreed upon and attainable for the patient's overall health. The plan will be reviewed and monitored on an ongoing basis by their Care Coordinator and presented to the medical provider.
Patients are eligible for the ChronWell program if they are enrolled in Medicare and have at least one chronic condition for the PCM program and at least two chronic contitions for the CCM program.
ChronWell helps the physician coordinate the necessary communication and care beyond the office and consult. How many times have patients left the office without truly understanding their next steps? With a busy practice, most physicians and their staff are not in a position to discuss in detail all of the necessary requirements of their patients care. The ChronWell program provides appropriate, frequent communication and touch points and acts as a clinical team member who is able to discuss this information with patients and their families.