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For   the   Patient 

Chronic Care Management is a Medicare program created to provide support to patients and strengthen the relationship between patient and healthcare provider. 

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Care Coordination

Each patient is assigned a care coordinator who will schedule appointments, provide solutions to any barriers in care, and help answer any questions. 

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VIP Access 

Care coordinators are available to answer questions regarding patient health. Non-emergent issues are relayed directly to the health care provider, ensuring the issue is addressed and a solution is found. 

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Goals are Determined

An electronic care plan is sent out every month summarizing the patient's health. It includes goals set by the patient, as well as condition specific goals set by the care team.  

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Condition Specific Goals 

Problem 

Goal 

Diabetes

Hemoglobin A1C < 7%

CAD

Aspirin taken once/day  

Diabetes/

CAD

Walk 30 minutes everyday

(patient goal)  

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