Chronic Care Management
Ongoing Support for Complex, Long-Term Conditions
Living with two or more chronic conditions means your health needs attention every day — not just at your next appointment. Our CCM program gives you a dedicated care team, a personalized care plan, and responsive support, all covered by Medicare and most private insurers.
What Is Chronic Care Management?
Chronic Care Management (CCM) is a Medicare-covered program that provides structured, ongoing support for patients living with two or more chronic conditions expected to last at least 12 months.
Unlike a standard office visit, CCM provides continuous care between appointments — monthly check-ins, a comprehensive electronic care plan, medication management, and coordination across all your providers. It's the proactive, connected care that patients with complex conditions have always needed.
Conditions We Manage
Our APRNs are experienced in supporting patients with a wide range of chronic conditions, including:
Don't see your condition listed? Contact us — we manage many additional chronic conditions. Eligibility requires two or more qualifying conditions.
What's Included in Your CCM Program
Every enrolled patient receives a comprehensive suite of care coordination services.
Personalized Electronic Care Plan
A comprehensive, up-to-date care plan documenting your conditions, medications, goals, and care team — shared securely across all your providers.
Regular APRN Check-Ins
Dedicated APRN time each billing period — reviewing your symptoms, medications, and progress toward your health goals.
Responsive Care Team Access
Have a question or concern between appointments? Reach your care team by phone for guidance, triage, and support.
Medication Management
Regular medication reviews to catch interactions, ensure adherence, and coordinate refills — reducing one of the most common causes of complications.
Specialist Coordination
We track referrals, share records, and follow up on specialist visits so your entire care team stays aligned.
Preventive Care Reminders
Proactive reminders for screenings, vaccinations, lab work, and follow-up appointments — so nothing important slips through.
How CCM Works Month to Month
Enrollment & Care Plan Creation
We verify your insurance, gather your medical history, and build a comprehensive electronic care plan in collaboration with your primary care provider.
Regular APRN Contact
Your dedicated APRN reaches out on a regular basis for a structured check-in — reviewing your conditions, medications, symptoms, and any new concerns.
Ongoing Coordination & Monitoring
Between check-ins, we coordinate with your specialists, track lab results, manage referrals, and update your care plan as your health evolves.
Insurance Coverage for CCM
Chronic Care Management is a covered benefit under Medicare Part B, and most private insurance plans cover CCM services as well. For most Medicare patients, there is little to no out-of-pocket cost.
Out-of-pocket for most Medicare patients
We will verify your coverage as part of the enrollment process — at no cost to you.
Check My EligibilityStart Getting the Ongoing Care You Deserve
If you have two or more chronic conditions and Medicare or private insurance, you likely qualify. Reach out to get started.
Questions? Call us at (702) 832-8746