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Chronic Care Management

Chronic Care Management for adults and kids

Care Managers can help a person with chronic conditions, behavioral health challenges, a parent with an autistic child, or a person with food insecurity to find a path to security and recovery. It can be overwhelming for patients with multiple chronic conditions to take the right medications at the right time and figure out how to balance the advice given by different healthcare providers.

Care Managers will ensure that patients are receiving coordinated, integrated care and will keep track of medications, appointments, follow-ups, and periodic testing for all of your health conditions.

Chronic Care Management (CCM) supports people who have multiple chronic health conditions such as:

  • Diabetes
  • High blood pressure
  • Heart disease
  • COPD
  • Congestive heart failure
  • Depression
  • Cancer
  • Arthritis
  • Osteoporosis

How does Chronic Care Management work?

Chronic Care Management involves coordination between your provider, pharmacy, specialists, testing centers, hospitals, and other services. CCM provides you with direct access to a Care Manager and Care Team that are available to you by phone, email, or direct face-to-face contact. This includes:

  • A dedicated Care Manager to coordinate appointments and communicate regularly
  • At least 20 minutes per month of phone or email Chronic Care Management services
  • Assistance with any community needs or services
  • Help managing medications
  • Assistance with setting and meeting your health goals

Who is eligible for Chronic Care Management?

People with two or more chronic conditions expected to last at least 12 months are eligible to receive Chronic Care Management services. Your Community Health primary care team will let you know if Care Management is right for you or your loved one, and they might recommend one of these programs:

  • Chronic Care Management (CCM) for qualified Medicare and Medicaid patients who opt into the program
  • Shared Care Planning through Vermont’s OneCare Accountable Care Organization

Chronic Care Management is a program that guides you on the right path to wellness by creating a manageable routine. 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.

Contact your healthcare provider at Community Health to enroll in the Chronic Care Management program and find out how to create a healthcare plan that considers all aspects of your care.


Chronic Care Management Locations

Community Health Mettowee

278 VT Route 149
West Pawlet, VT 05775

Community Health Brandon

420 Grove Street
Brandon, VT 05733

Community Health Castleton

275 Route 30 North
Bomoseen, VT 05732

Community Health Rutland

215 Stratton Road
Rutland, VT 05701

Community Health Shorewell

2987 VT Route 22A
Shoreham, VT 05770