Chronic Care

We Are a Partner in Helping Patients Manage Chronic Diseases

Community Health & Wellness Partners offers a Chronic Care Management (CCM) program that provides extra nursing involvement and medical care to patients who have difficulty managing their chronic diseases alone. Our program is nurse-driven, and our goal is to serve patients by creating a partnership and providing individualized chronic care services that promote their ability to live successfully with chronic illnesses.

We offer chronic care management services to any patient at Community Health & Wellness Partners who has the need and would benefit from the chronic care services. While chronic care management is frequently associated with Medicare patients, we do not limit our patients’ access to these services. At Community Health & Wellness Partners, chronic care services are offered to any qualifying patient, regardless of their insurance type.

Who is eligible?

Enrollment in chronic care management is ideal for patients with multiple chronic conditions that they are not managing well or patients with a high-risk diagnosis, such as diabetes, asthma, uncontrolled hypertension, congestive heart failure, chronic obstructive pulmonary disease or chronic kidney disease. Patients who have made multiple emergency room visits or who have multiple hospital admissions would also benefit from chronic care services, as would patients who are feeling overwhelmed by a new diagnosis of a chronic condition or a patient who has health literacy issues or lacks support at home.

How does a patient benefit?

Patients enrolled in a chronic care management plan receive a personalized plan of care that also provides access to a “go-to” nurse between appointments. These patients also receive extra support and education to help them coordinate care with specialists and with all team members at Community Health & Wellness Partners. As a result of these chronic care services, patients often experience a reduced number of emergency department visits or hospitalizations and an improved overall happiness and well-being, and they learn how to self-manage diseases so that they can live a healthier life.