Chronic Care Management

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:

  • Care coordination between the practice and patient
  • Referral 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 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.


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 Chronic Care Management, schedule a call with ChronWell today.

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