Chronic Care Management

Chronic care management services are known to address some of the health and financial burdens associated with chronic illnesses for patients. The benefits of chronic care management services have been described in a number of studies. One large study of telephone care management services demonstrated success in improving patient satisfaction and communication with care providers, enhancing self-management skills, increasing use of preventive services, and decreasing hospitalizations and medical costs

The Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals. Infectious Disease Consultants offers a comprehensive Chronic Care Management program to its patients.

Patient Resources: 

Chronic Care Management Explained PDF

Why Chronic Care Management is a Benefit to Patients & Providers

Examples of Chronic Care conditions:

Alzheimer’s disease and related dementia

Arthritis (osteoarthritis and rheumatoid)

Asthma

Atrial brillation

Autism spectrum disorders

Cancer

Cardiovascular Disease

Chronic Obstructive Pulmonary

Diabetes

Hypertension

Infectious diseases such as HIV/AIDS

Comprehensive Care Plan

A comprehensive care plan for all health issues typically includes, but is not limited to, the following elements:

  • Problem list
  • Expected outcome and prognosis
  • Measurable treatment goals
  • Symptom management
  • Planned interventions and identi cation of the individuals responsible for each intervention
  • Medication management
  • Community/social services ordered
  • A description of how services of agencies and specialists outside the practice will be directed/coordinated
  • Schedule for periodic review and, when applicable, revision of the care plan