Patient with caregiver.


The Chronic Care Management (CCM) program is designed to address the needs of the top 10% of health care utilizers for a health plan. CCM is a care program where our doctors become the Primary Care Physician (PCP) for patients. These doctors provide care (exams, follow-up visits, etc.) in the patient's home.

Patient Qualifications for CCM

Patients are referred to CCM by the health plan after consultation with the patient’s PCP. Patients 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
What Physicians need to know if their Patient is enrolled in CCM
  • Our doctors will become the Primary Care Physician for patients selected by the health plan.  After a consultation with the original PCP, our doctor will become the PCP for selected patients and provide care primarily in the home.
  • Patients receive personalized in-home care.  Our doctors help with specific medical care and patient decisions -- from medications and equipment to preventive screenings.  Typically, our doctors will visit on a monthly basis.  However, the frequency of visits will depend on the patient’s condition.
  • Patients have a full support team.  Our doctors, nurse practitioners, and registered nurses (telephonic support team) work with many other local community resources to meet all of your medical care needs.
How physicians benefit from Chronic Care Management:
  • Improved Medical Loss Ratio and P4Q measures – leads to financial benefits for physicians
  • Increased quality/ HEDIS measures
  • Improved health outcomes for your patients
  • Reduced burden on office resources caused by high utilizing patients

Factsheets & Information