Chronic Care Management

Managing multiple chronic conditions can be overwhelming, but you don’t have to do it alone. Our Chronic Care Management program helps Medicare patients stay on track between visits, prevent unnecessary hospital or ER trips, and receive consistent, personalized support.

What is Chronic Care Management?

Chronic Care Management for Medicare patients with ongoing health conditions.
We provide ongoing support for individuals with two or more chronic conditions expected to last 12 months or longer. Through regular communication and personalized care coordination, our team helps patients better manage their health, medications, and appointments—improving quality of life while reducing hospital visits.

Dedicated Nurse Care Coordinator

Direct Phone Access

Managing your Health Between Visits

Medication Management 

Personalized Care Plan

Compassionate, Judgment-Free Care

Chronic Care Management acts as a bridge between patients, their families, healthcare providers, and community resources. Our care coordinators ensure that everyone involved in your care stays connected and informed.

What to Expect on Your Visit

 Initial Consultation

Meet your care coordinator to review your health history and goals.

Complete Screening Questions

We assess your needs and identify areas where extra support can help.

Personalized Care Plan

Together, we build a plan to manage your conditions and stay on track.

Regular Check-In Calls

Expect phone calls every 1–3 months depending on your health needs.

Ongoing Care Between Visits

Most CCM support is provided by phone, keeping you connected between appointments.

Specialists and Community Resources

We connect you with the right specialists and local services to ensure all aspects of your health are supported.