Chronic Care Management

Pomerene

Chronic Care Management


What is Chronic Care Management (CCM)?

In January of 2015, Medicare introduced Chronic Care Management (CCM) as a way to help providers improve healthcare outcomes for those with chronic conditions.


Pomerene Family Care and Pomerene Internal Medicine now offer CCM at all outpatient locations.

Who Benefits from CCM?
  • Those who feel overwhelmed and struggle to keep up with multiple prescription and healthcare needs
  • Isolated and elderly patients with a limited support system
  • Patients with psycho-social challenges and low medical literacy
  • Those who would benefit from between-appointment medical oversight, education and encouragement
CCM Benefits Patients by Helping Them:
  • Reduce unnecessary hospitalizations and readmissions
  • Coordinate multiple medical services and specialties
  • Become more engaged in their healthcare experience
  • Keep follow-up appointments and remain current on preventative services
  • Keep track of medications, dosages and refills
  • Recognize developing symptoms or changes before they escalate

What does a CCM Case Manager Do?


  • Serves as an extension or resource between the patient and provider
  • Provides a systematic assessment of the patient's medical, functional and psycho-social needs
  • Assists with the scheduling of recommended preventive care services
  • Provides medical reconciliation and oversight of patient's self-management of medications
  • Supports 24/7 patient access to care and health information
  • Provides telephone interaction with patient and healthcare providers to discuss healthcare needs and goals



Who Qualifies for CCM?


  • Patients that have been evaluated within the past year
  • Patients receiving Medicare/Medicaid benefits and those with private insurances
  • Patients that have multiple (two or more) chronic conditions expected to last at least 12 months
  • Patients with conditions that place them at significant risk of death, acute exacerbation/decomposition or functional decline
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