Care Connections: A Chronic Care Management Program
Care Connections is a preventive service that doctors can recommend to their Medicare patients who have chronic conditions such as high blood pressure, high cholesterol, diabetes, heart disease, and arthritis. Care Connections supports patients in achieving a better quality of life. Medicare now encourages doctors to recommend Care Connections to beneficiaries who have multiple conditions that are very common among Medicare patients and put them at risk for declining health and hospitalizations.
The Care Connections program includes you and your entire healthcare team. The Care Connections managers are specially trained nurses, or other healthcare professionals who know you, your medical history, and your goals. Best of all, you don’t have to leave the comfort of your own home! Your care manager will visit with you in your home at enrollment and then by phone every month. With help from Care Connections, you can successfully reach your goals!
How Care Connections Can Help
- Monthly progress checks to ensure goals are being achieved
- Ensuring prescriptions are current and medications are taken properly
- Coordinating care and scheduling appointments with others such as specialists, pharmacists, and therapists
- Arranging community services such as Meals on Wheels, home health, medical equipment, and public transportation
- Assisting with Medicare, Medicaid, social security, disability, and medication assistance programs
- Providing regular updates to primary care providers
- Providing education on nutrition, medical conditions, and how to improve overall health
Developing Comprehensive Care Plans
Through the Care Connections program, an individualized, comprehensive care plan is devised for all health issues that typically includes some or all of the following elements:
- Planned interventions
- Community and social services needed
- Descriptions of how services are directed/coordinated
- Schedule for periodic review and, when applicable, revision of the care plan
Chronic care management or CCM is the provision of care management to patients with two or more chronic conditions:
Newman Regional Health Medical Partners was recently recognized by the Kansas Healthcare Collaborative as one of eleven medical practice groups with a combined score in the top 25% of baseline assessments for Population Health and Chronic Disease Management, also known as the 1815/1817 Assessment.