Chronic Care Management Overview

The Centers for Medicare and Medicaid Services (CMS) define chronic care management as “services by a physician or non-physician practitioner and their clinical staff, per calendar month for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.”

  • Monthly assessment of your medical, psychosocial and functional needs by a dedicated nurse or nurse practitioner.
  • Monthly review of your medications and your use of the medications that you are self-administering.
  • Oversight of preventative services
  • Professional guidance for your medical questions and concerns
  • Follow up to any transitions with institutional and community based healthcare providers transitioning to home.
  • Coordination of all of your health wellness visits as well as with other health professionals.
  • Monthly updates and maintenance of a Certified Electronic Health Record (Care Plan), with a patient portal that you and your doctors will be able to access to minimize gaps in communication.

The fact that chronic care management promotes a better quality of life by contributing to program enrollee’s improved health and lower healthcare costs, has caused the Center for Medicare and Medicaid Services to develop and promote chronic care management programs. Persons enrolling into the chronic care program must have been seen by their health professional in the past year, prior to the initial phone call visit. A comprehensive care plan will be developed with you. This care plan will be monitored and shared with all of the medical professionals that are involved with your care. The Nurse In Touch care manager will update your care plan every month, as needed. This will assure that all of your health professionals are working with the same information through access to the care plan, allowing for better care coordination.

Your Nurse In Touch uses “state of the art” computer software to keep everyone associated with your care current in their knowledge about your complete medical picture, through the use of computerized reports, emails and other forms of notification. In addition to your primary care physician, you will always have a knowledgeable, informed, caring team working on your behalf. There is a Medicare $8 per month co-pay for chronic care management, which is paid for by Medicaid, Medi-Gap and all other Medicare secondary health insurance coverage. Even if there were no coverage, all of these services being provided to assure your health and safety, in addition to the potential medication cost savings, would be a bargain. Your Nurse In Touch will assist you in seeking co-payment coverage if you do not have Medicaid or Medicare secondary insurance.