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Chronic Care Management

A Partnership for Your Health

Find out if Chronic Care
Management is right for you

Who is eligible to receive CCM and how do I enroll?

People with two or more chronic conditions expected to last at least 12 months are eligible to receive Chronic Care Management services. Medicare and Medicaid recognize Chronic Care Management as a critical component of primary care that contributes to better health and care for individuals. Ask your health care provider at Community Health Centers of the Rutland Region for details about Chronic Care Management and how to enroll in the program.

Our patients who are enrolled in the Chronic Care Management program are already benefiting from the coordinated care it provides.

Get started on a path to wellness with CHCRR and Chronic Care Management.

Contact your healthcare provider at Community Health Centers of the Rutland Region to enroll in the Chronic Care Management program and find out how we can help you create a health care plan that takes into account all aspects of your care.

Here are some success stories:

“After a home visit done with a patient getting out of the hospital, he wasn’t able to get to the office and was confused about his medication. I reviewed his meds and discussed our program. His response was, ‘I think that this is great that you offer this program.’ He and his wife were very happy.”

— Melissa, Care Manager

“An elderly patient with multiple medical issues was taking 27 medications by multiple prescribers. I helped organize and update the current medications to avoid confusion about instructions for use. The education I provided was greatly appreciated. Coordination with the pharmacy and with specialists was crucial to avoid re-hospitalization. I continue to check with the patient on a monthly basis.”

— Susan, Care Manager

What is Chronic Care Management?

What is Chronic Care Management?

Chronic Care Management (CCM) is a system to support people like you who have multiple chronic health conditions. It’s often difficult and frustrating to keep track of medications, appointments, follow-ups and periodic testing for all of your health conditions. CCM is a coordinated approach to keeping you healthy by providing a comprehensive care plan designed specifically for YOU. It is designed by your health care providers and coordinated with all of their input. The plan is developed in collaboration with your doctors, nurse practitioners and other staff who are involved in your overall care.

At Community Health Centers of the Rutland Region (CHCRR), we want you to be fully engaged and receive the best care possible from everyone who is involved in your treatment plan.

Managing Your Care Means:

  • Facilitating and coordinating your visits with all healthcare providers, offices, labs, radiology and other testing facilities you may need
  • Providing you with a Care Manager that you can contact when you need help or have questions
  • Talking to you by phone about your chronic care needs and challenges
  • Helping you manage your medications
  • Providing you with an easy to understand and complete care plan

The coordinated team approach to caring for people with multiple chronic conditions like you is a benefit offered through Medicare. And, because Medicare supports the Chronic Care Management approach to your healthcare, Medicare benefits are available for costs associated with CCM.

What are some chronic conditions?

Chronic care management offers help managing conditions like arthritis, asthma, diabetes, COPD, high blood pressure, heart disease, osteoporosis and many others.

Why is it Important for me to enroll in CCM?

Medicare requires that you enroll in the Chronic Care Management program in order to offer all of the programs and systems needed to coordinate your care. It gives you access to the providers and resources available to you.

It can be overwhelming for patients with multiple chronic conditions to take the right medications at the right time, or to figure out how to balance the advice given to you by different health providers. Chronic Care Management is a program that guides you on the right path to wellness by creating a manageable routine.

Once you enroll in CCM, you will spend less time managing your care and have more time to focus on the other important parts of your life like your family, your home or your job!

How does Chronic Care Management work?

CCM can simply be a phone call or email to or from your healthcare team. These resources are available to you 24 hours a day, 7 days a week. You don’t need to go into the office in order to ask a question or get an update on a medication or a lab result. Information about your care plan and a list of your providers is coordinated in one place, so all of your providers have access to the status of your care and the latest updates on your chronic conditions.

What services does CCM provide?

  • Personalized help from a dedicated Care Manager who will work with you to set up ongoing appointments and communicate with you regularly
  • Care coordinated between your doctor, pharmacy, specialists, testing centers, hospitals and other services
  • At least 20 minutes per month of phone or email chronic care management services
  • Phone check-ins between face-to-face visits with providers
  • Expert help setting and meeting your health goals
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