A patient with two chronic conditions sees their physician a handful of times a year. The other fifty weeks are where the care plan either holds or quietly falls apart.
What the program covers
Chronic care management is ongoing, non-face-to-face care between appointments. In practice that means a familiar voice calling every month, reviewing what changed, and passing findings straight back to the care team.
- Monthly one-to-one check-ins with every enrolled patient
- Medication review, with findings reported to the prescriber
- Outreach for screenings and preventive visits coming due
- Help reaching transportation and assistance programs
Which patients qualify
Typically patients with two or more chronic conditions expected to last at least a year. The exact criteria depend on your program and payer requirements, which is what the free consultation reviews against your own panel.
How it differs from transitional care
Transitional care management covers the weeks right after a discharge. Chronic care management is continuous, month after month. Running both, coordinated, is what keeps a patient from falling between the two.
