Digital Care Management

Every patient is unique, but comorbidities are common.  ChronWell already helps many practices manage common digestive conditions like IBS, GERD, IBD, and Chronic Constipation under existing care management and remote monitoring codes.  By combining new technologies with our proven medical specialty expertise we can offer you a profitable way to care for patients beyond the walls of the practice.


The ChronWell Digital Care Management 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 Care Navigator (PA, NP, MA) will work with patients remotely and will include:

  • Care coordination between the practice and patient
  • Important symptoms management
  • Medication management
  • Care plan adherence
  • Specialty Specific Programs

The designated Care Navigator 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 (in the office or telemedicine) and also includes 24/7 access to a clinician. The physician will receive the patient's care plan and monthly updates as the patient works with the Care Navigator.


How We Measure Program Success



  • Maximizing patient enrollment
    • Office enrollment
    • Telephonic enrollment
  • Meeting set financial goals for the practice
  • Increasing appropriate office visit opportunities


  • Medication and medical adherence tracking
  • Coordination of care and referal management 
  • Ongoing review of medical status and risk
  • Lifestyle changes and healthy habit development

Patient Engagement

  • A minimum of 20 minutes of monthly clinical staff time 
  • Provide education to the patient, family and caretakers
  • Serving as the liaison between the patient and the practice
  • Stress and anxiety coaching 
  • Assistance with Remote Patient Monitoring (RPM)


  • Patient satisfaction
  • Cost to provider of acquiring patients
  • Revenues generated to provider

To learn more about Digital Care Management, schedule a call with ChronWell today.

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