Chronic Care Management

Chronic Care Management is a programme that puts a care team around you between office visits. More than a thousand of our patients are enrolled. It exists because the gap between appointments is where most people lose ground.

What the care team actually does

• Checks in on a schedule — a real person, by phone, in your language, without you having to chase anyone
• Watches your readings between visits — blood pressure, blood sugar, weight and oxygen levels, and contacts you when a number drifts rather than waiting for your next appointment
• Sorts out medications — refills that stalled, pharmacy problems, coverage issues, and the question of whether you can actually afford what you were prescribed
• Chases referrals and makes sure specialist results come back to us and get explained to you
• Keeps one care plan that everyone involved is working from, rather than four different plans from four different offices
• Follows up after a hospital stay, which is when readmissions happen
• Gives you a number to call when something changes and you are not sure whether it matters

Who may qualify

Generally, patients with two or more chronic conditions expected to last at least a year — for example diabetes with high blood pressure, or COPD with heart disease and kidney disease. Eligibility and any cost depend on your insurance, and Medicare covers these services for patients who meet the criteria.

We will tell you plainly whether you qualify and what, if anything, it will cost you before you enrol. Nobody is enrolled without agreeing to it.

How to join

Ask at your next visit, or call the clinic and say you want to know about Chronic Care Management. Enrolment takes a short conversation and a consent form, which you can also download in advance from Patient Resources.