Chronic Care Management (CCM) is a program available to patients living with more than one chronic condition, such as arthritis, diabetes, depression or high blood pressure. Goal of CCM is to improve quality of life through symptom management, prevention of further complications, and promoting self-management.
Care coordination
Marshfield Medical Center-Dickinson offers a service that can help you navigate these challenges. Our CareHarmony care coordination service is designed to help you take care of you. You will benefit by receiving monthly telephone assistance in between your regular appointments. This includes a dedicated care coordinator to guide you toward better health.
CCM extends your care outside the four walls of your physician's practice to ensure that you maintain the best possible health. Here's what CCM can do for you:
- Assist with scheduling appointments, lab tests or other tests.
- Explain how and when to take your medications.
- Coordinate any home health or medical equipment needs.
- Connect you with health education resources, services and programs.
- Identify available community resources.
- Coordinate follow-up care after leaving the hospital.
- Access other support services you need to stay well.
- Help facilitate palliative care and hospice transitions.
- Assist with advance care planning.
A 24/7 care coordinator phone line is available to help answer any questions you may have day or night, outside of your calls with your care coordinator.
Cost and coverage
This service is covered by Medicare and other payers and is subject to your annual deductible and coinsurance (usually 20%). If you have a secondary or supplemental insurance plan, your coinsurance may be covered. It is best to review exactly what your insurance plan covers.
How to enroll: While you can only sign up for CCM services with one of your CareHarmony care coordinators, you are able to opt out any time—there are no strings attached.
You may also seek a referral from your primary care provider for care management services. Referrals are passed along to in-house care coordinators affiliated with the clinics. This is an option in addition to CareHarmony.
Contact us
If you have questions about this service and would like to learn more about this program or how to enroll, please call your primary care provider.
Find out more about CareHarmony here.
CCM FAQ
What is Chronic Care Management?
Chronic Care Management (CCM) is a care coordination program designed by Medicare to help patients better manage their chronic conditions. It was designed to give you greater support and access to care between office visits, even while at home.
What is a chronic condition?
A chronic condition is an ongoing, long-lasting health condition that requires continual management and treatment. Left untreated, a chronic condition can hinder independence and negatively impact health. A few examples of chronic conditions include asthma, diabetes, arthritis, hypertension and heart disease.
What is care coordination?
Care coordination is the deliberate organization of patient care activities and sharing information among all participants concerned with a patient’s care to achieve safer and more effective care. Care coordination services (like those that are part of Medicare’s Chronic Care Management program) provide extra layers of support and care between doctor visits to eligible patients who have two or more chronic conditions.
Who is eligible?
To be eligible for the Chronic Care Management program, you must be a Medicare beneficiary and have multiple (two or more) chronic conditions expected to last at least 12 months, or until end of life. If you are unsure if your conditions qualify, contact your primary care provider and they will be able to assist you further.
Do I have to be a Medicare member?
Yes. At this point, the CareHarmony program is only being offered to Medicare patients. Other in-house care coordination may not have Medicare enrollment as a requirement.
Why does my doctor want this for me?
Managing and coordinating care can be especially difficult if you suffer from multiple chronic conditions. You may be seeing different types of doctors or taking several medications. For every medication you take, it’s important to know how it reacts with other medications. For every doctor you see, there are test results or health information that needs to be shared. When your care is coordinated properly, your doctors get the information they need when they need it. This creates a comprehensive, multi-disciplinary approach to care and management of your conditions.
But what if I feel fine?
One of the great benefits of Chronic Care Management is not only to help you achieve good health, but also to maintain it. That’s why the program also focuses on things like helping you keep on top of preventive care and helping you locate specialists, valuable healthcare resources and community services.
What does this program cost?
Most Medicare patients have secondary insurance, which often covers CCM program co-pays. In instances where this isn’t the case, CCM services may be subject to a modest copay (usually 20%), as well as your deductible. It is best to review exactly what your insurance plan covers.
Is my information private and secure?
Yes. The same rules that protect your medical information in your doctor’s practice apply here as well. Your information is and will always be secure, using the latest certified information technology and following all HIPAA guidelines.
Why should I enroll?
Chronic Care Management extends your care outside of the four walls of your physician’s practice to help you maintain the best possible health. You will be matched with a dedicated care coordinator and have access to help 24/7. A treatment plan (care pathway) will be created to plan for your ongoing care and better address all your health-related issues. Your care coordinator will be there for you helping you navigate the healthcare system, including scheduling appointments, helping with refills, and answering lingering questions. Your care coordinator acts as an extension of your doctor and helps your doctor monitor and adjust your care accordingly.
How do I enroll?
Please call your primary care provider to learn more about how you can benefit from this program and to gain answers to any questions you may have.
How do I opt-out of the program?
With Chronic Care Management, there is no long-term commitment. You may opt out any time by notifying us via phone and you will be unenrolled at the end of the current month.
