Principal Care Management

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:

  • Care coordination between the practice and patient
  • Referal management 
  • Medication management
  • Care plan adherence

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. 


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 30 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 Principle Care Management, schedule a call with ChronWell today.

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