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Our Chronic Care Management (CCM) program is a high-touch care model where our physicians directly manage your member's care in the comfort of their own homes. We focus on a health plan's top 10% of health care utilizers and assume the role of primary doctor for these members. Treating and visiting in the home allows us to develop a more personalized care plan to address their needs.

Partnership with the Health Plan

Alegis Care will work with the health plan and the original primary care physician to better understand the historical and recent treatment and care. Once we confirm that our health professionals will manage the care of the member, the following steps will generally occur:

  • Our doctor will conduct a full physical exam and review medications that the member currently takes
  • Based on results of the exam, the doctor will develop a care plan and share with the member and pertinent caregivers
  • Our doctor and team will visit the member in their home on routine basis (usually monthly).  Frequency of visits will be determined by the personal care need.
Members Who Qualify for CCM

Members who qualify for CCM generally have more than 2 hospitalizations and/or more than 3 emergency room  visits in the year prior to referral.  The members are chronically ill with multiple uncontrolled comorbidities  including:

  • Heart Failure (CHF)
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Asthma
  • Chronic Kidney Disease
  • Diabetes Mellitus
  • Coronary Artery Disease
  • Dementia
Alegis Care Team

The team that will care for your members is led by a board-certified physician who is supported by in-home nurse practitioners, telephonic registered nurses, and a central Customer Service hotline.

Our doctors and nurses live in the areas that they work.  As such, they have developed relationships with other health resources that may be needed for care such as:

  • Specialists
  • Diagnostic labs
  • Home health agencies
  • Hospice
  • Social agencies

Factsheets & Information