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Chronic Care Management

Sometimes, patients with chronic illnesses need a little help managing their conditions. It can be overwhelming to understand medications, schedule and track visits with specialists, and coordinate care on their own. Community Memorial’s Chronic Care Management team is here to help.

Chronic Care Management is for patients with fee-for-service Medicare insurance coverage who have two or more chronic conditions, such as diabetes and hypertension, and are having difficulty meeting their treatment goals. Patients must be referred by their primary care provider for enrollment into the program.

Services include:

  • Personalized care plans
  • Medication review and education
  • Phone check-ins between scheduled appointments
  • Goal setting regarding nutrition, weight management, and physical activity
  • Chronic disease self-management, monitoring, and education
  • Coordination and scheduling of preventative care
  • Help obtaining notes from consultations, Emergency Department reports, hospital records, and diagnostic reports
  • Connection to other community resources or care as needed

If you would like to learn more, call 805-948-3059.