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
