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. Options for specialists where a patient has one chronic condition is also available.
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 Care Navigator (PA, NP, MA) will work with patients remotely and will include:
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 and also includes 24/7 access to a clinician. The physician will receive the patient's care plan and monthly updates as the patient woks with the Care Navigator.