Chronic Care Management (CCM) is the coordination of care outside traditional medical visits for patients with two or more chronic conditions. The (CCM) program establishes consistent patient-provider relationships, offers customized patient-centric healthcare education while increasing patient satisfaction. Through CCM, South Carolina & Georgia House Calls (SC & GA HC) will deliver a coordinated level of care that seeks to improve its patients' overall health and quality of life.
Patient benefits associated with (CCM) include:
• Team of dedicated professionals:
SC & GA HC specializes in a proactive team approach to healthcare delivery that improves communications between providers and specialists and streamlines patient care transitions, referrals, and follow-ups.
• Care Plan:
Each enrolled CCM patient starts with a comprehensive care plan that evaluates the complete patient and sets health management goals that include physical, cognitive, psychosocial, functional, and environmental factors.
• Engagement:
Having additional touch points each month between on-site visits helps patients remain engaged in their care. Education on medication adherence, fall risks, and other self-management tasks keeps patients involved and on track with treatment plan goals.
• Access:
The (SC & GA HC) Center for Telemedicine, a 24-hour, 365-day operation, provides (SC & GA HC) patients access to medical professionals who can assist with questions or concerns at any time. In addition, a patient portal is available that provides a secure pathway for communications with a patient's provider team.
• Complications:
With CCM providing a higher level of managed care, patients mitigate their risks of experiencing preventable healthcare events that can lead to emergency room visits and hospitalization.
The CCM enrollment process is simple and can be either a written or verbal agreement. Patients must consent to receive CCM services, and the consent is documented in the medical record. Patients must also be informed that they can stop receiving CCM services at any time.
