Chronic Care Management
Ongoing Support for Patients Living with Chronic Conditions
If you're living with one or more chronic conditions — like diabetes, high blood pressure, heart disease, COPD, or arthritis — Chronic Care Management (CCM) is a program designed to give you extra support between office visits. Through CCM, our care team checks in with you regularly by phone to help you stay on track with your health goals, manage your medications, and address concerns before they become bigger problems. It's one more way we're here for you.
Why did my doctor recommend CCM?
The purpose of the Chronic Care Management (CCM) program is to help patients with chronic conditions better manage their self-care and optimize their health.
Chronic conditions require consistent attention, not just yearly checkups. Regular check-ins help your healthcare provider catch small changes before they become serious problems.
Staying on top of medications, lifestyle habits, and follow-up care is a lot to manage on your own. CCM gives you a knowledgeable team member in your corner.
Research shows that patients enrolled in CCM programs have fewer emergency room visits and hospitalizations — meaning you spend more time feeling well and less time in crisis.
Your healthcare provider wants a complete picture of how you're doing between visits. CCM keeps that communication open and your care plan up to date.
If you're managing multiple conditions or seeing more than one provider, CCM helps make sure all of your care is coordinated and nothing gets missed.
What to Expect
Ongoing, coordinated support between your regular office visits.
A member of our care team will reach out to you by phone each month for a brief check-in — typically 20 minutes or more.
We'll review how you're feeling, go over your medications, and make sure your care plan still fits your needs.
If something comes up between visits, CCM gives you a direct line to our team for guidance and support.
We'll also help coordinate any referrals, specialist visits, or community resources you may need.
Common Questions
CCM is available to patients who have two or more chronic conditions that are expected to last at least 12 months. If your healthcare provider enrolled you in this program, it's because they believe you'll benefit from a little extra support — and we're glad to offer it.
Participation is completely voluntary. You can opt in or out at any time, just let us know. If you ever have questions about whether CCM is right for you, we're happy to talk it through.
CCM is a Medicare-covered service, and most supplemental insurance plans cover it as well. Depending on your plan, there may be a small copay. Our team can help you understand your coverage before you get started.
That's perfectly fine — and actually one of the things CCM helps with. We can help coordinate care across your different providers so everyone is on the same page and nothing falls through the cracks.
No worries — we'll try again. Life gets busy, and we understand. Just give us a call back when you're able, or we'll reach out to reschedule.
You're not doing this alone.
Living with a chronic condition takes real effort. We see that, and we want to make sure you never feel like you're doing it alone.
Questions? Give us a call — we're happy to help.