Patient with care giver


Our Chronic Condition Programs are designed to address the needs of the top 5% of health care utilizers. Chronic Care Management (CCM) is a care program where our doctors become the primary care physician (PCP) for patients, and Complex Care Program (CCP) is a care program that allows our nurse practitioners to collaborate with you and extend care to a patient's home.

Patient Qualifications for our Chronic Condition Programs

Patients are referred to our programs by the health plan after consultation with you. Patients who benefit most generally have more than 2 hospitalizations and/or more than 3 emergency room visits in the year prior to referral and 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

The members who benefit from our CCM program are also either homebound or lack access to care.

What You Need to Know if Your Patient is Enrolled in Our Chronic Condition Programs
  • For CCP, you will remain the patient's primary doctor. The Alegis Care CCP program provides in-home care support for patients, which can be helpful for patients that have difficulty getting to your office. Our providers follow the care plan developed by you, and we will transition the patient back to you full time if and when appropriate.
  • For CCM, our doctors will become the primary care physician for patients selected by the health plan. After a consultation with you, our doctor will become the PCP for selected patients and provide care primarily in the home. We will transition the patient back to you if and when appropriate.
  • Patients receive personalized in-home care. Our providers help with specific medical care and patient decisions -- from medications and equipment to wellness exams. Typically, our providers will visit on a monthly basis. However, the frequency of visits will depend on the patient's condition.
  • Patients have a full, telephonic support team. Our doctors, nurse practitioners and registered nurses work with many other local community resources to meet all of your medical care needs.