Chronic Condition Management

Chronic Condition Management

Patients with multiple chronic conditions* are more likely to be hospitalized and have restrictions on their ability to work and engage in daily tasks.

Our team recognizes that for patients with two or more chronic conditions, a little extra attention can go a long way. This means better management of their health care needs, helping stay healthier without extra office visits. This could mean the difference between a weekend at home with family or hours spent in the emergency room.

Avance Care’s Chronic Condition Management service is designed to meet Centers of Medicare and Medicaid Services Chronic Care Management (CCM) program. It includes a minimum of 20-minutes of non-face-to-face time per month with patients in coordinating care, medication management, and much more.

What This Means to You as a Patient

  • Ongoing chart review to identify issues that should be discussed and addressed
  • Ensure medications are working and assistance to keep track of which medications to take and when
  • Coordinated care between specialists, testing centers, and hospitals to make sure everyone is working together
  • Assistance in making follow-up appointments and appointments with specialists
  • Monthly check-in, more personalized attention to patient and their health management goals
  • We are always available to answer any questions
  • *Chronic conditions include but not limited to diabetes, hypertension, cancer, COPD, Cardia conditions (CHF, Cardiomyopathy, CAD), asthma, arthritis, renal failure, etc.

How It Works

Our care team will call you once a month at a minimum. We discuss your current plan of care, any problems or concerns you have, and difficulties you may be facing with your health goals and treatment. You will receive a written care plan with goals for your health at least once a month.

Cost Effective

Chronic Care Management can lower your out-of-pocket costs, helping you save money by visiting the office less often and enjoying better health.

Who is Eligible?

Any person enrolled in Medicare or Medicare Advantage who has two or more chronic conditions can participate. Example conditions include diabetes, hypertension, cancer, COPD, Cardiac conditions (CHF, Cardiomyopathy, CAD), asthma, arthritis, renal failure, etc.

The small number of patients who do not have a secondary insurance or a Medicare Advantage plan may incur coinsurance similar to other Medicare services at approximately $8 per month.