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Intensive Diabetic Care For Patients wit

We service patients with many types of chronic disease including Alzheimer's, Asthma, COPD, Diabetes, Hearth Disease, Obesity, Parkinson's Disease, and more. We believe that patients with chronic conditions have an important role in the management of their conditions. The CCM program is a partnership between your healthcare provider and your self care.


Historically, Edward H. Wagner, MD, MPH, Director Emeritus of The MacColl Institute for Healthcare Innovation, and former Director of The Robert Wood Johnson Foundation national program conducted research on the interactions between healthcare facilities, providers, and treatments of chronic illness care developed the chronic care model, or CCM. This service is essential for our health care team to work effectively for you. The monthly program (most insurance plans cover the monthly fee, although co-pays, co-insurance, and deductibles apply) helps patients with two or more chronic conditions by providing 24/7 access using an interactive patient portal, coordination of health care records, labs, and diagnostics, and connection with local services when necessary, among the many other requirements for CCM patients. All patients accept the terms of CCM at their initial intake appointment. 


Our CCM patients have expressed great appreciation for these services with 1) improved access to their health care, 2) immediate response to health care questions, 3) improved coordination of complex health records between providers and management by our team, and 4) assistance with community needs (such as membership at a gym or installation of vital service in home). Here are your benefits that are provided by Medicare and Medicare Advantage plans for health practices that elect to follow the CCM guidelines.


  • Record the patient’s demographics, problems, medications, and medication allergies using certifed EHR technology. A full EHR list of problems, medications, and medication allergies must inform the care plan, care coordination, and ongoing clinical care.

  • Provide 24/7 access to physicians or other qualifed practitioners or clinical staf, including providing patients or caregivers with a way to contact health care practitioners in the practice to discuss urgent needs no matter the time of day or day of week.

  • Provide continuity of care with a designated practitioner or member of the care team with whom the patient can get successive routine appointments.

  • Electronically capture care plan information and make it available promptly both within and outside billing practice with individuals involved in the patient’s care, as appropriate.

  • Enhanced communication opportunities: Provide patients and caregivers enhanced opportunities to communicate with their practitioners about their care by phone and through secure messaging, secure web, or other asynchronous non-face-to-face consultation methods (like email or secure electronic patient portal).


  • Care coordination using certifed EHR certified technology (continuity of care documents, close the referral through consult reports. 

  • Communicate with patient by phone or electronically for care coordination

  • Medication management 

  • Transitional care management

  • Symptom management


  • Community resource referral and linkage

  • Coordinate community and social support service

  • Disease self-management education and support

  • Health coaching

  • Health education, including health literacy

  • Interventions to reduce falls or risk factors for falls

STEP 1: You will have an intake or regular appointment with your physician.

STEP 2: The provider will activate these benefits if they are applicable to your care at the time of your appointment.

STEP 3: You will receive a benefits activation letter in your patient portal.

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