Care Connections: chronic care management
Care Connections is a preventive service that doctors can recommend to their Medicare patients with multiple conditions like high blood pressure, high cholesterol, diabetes, heart disease, and arthritis. Care Connections helps patients make better decisions about diet & activity.
Care Connections are members of your healthcare team. They are specially trained nurses, or other healthcare professionals who know you, your medical history, and your goals. They will connect with you every
month and can help you prevent emergency room visits and hospitalizations.
Care Connections: Stay in the convenience of your own home
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 or by phone every month.
How a care manager can help
- Conversing with you monthly to track progress on achieving your health goals
- Ensuring prescriptions are current and that you are taking medications properly
- Coordinating care with other care team members like specialists, pharmacists, therapists, and scheduling appointments
- Arranging for community services like Meals on Wheels, Home Health, home medical equipment and public transportation
- Assisting you with Medicare, Medicaid, Social Security, Disability and medication assistance programs
- Providing regular updates to your primary healthcare provider
- Providing education about nutrition, your medical conditions and how to improve your health
- Answering your questions and meeting your care needs
Care Connections: Doctor recommended
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.
With their help, you can establish a plan that gets you to your goal, no matter how large or small.
Care Connections: Paid for by Medicare
Your doctor has recommended Care Connections because it can help you stay on track and out of the hospital and is covered by Medicare.
During your Care Connections monthly visits, your care manager will help you stay on track by reviewing the following topics:
Chronic care management or CCM is the provision of care management to patients with two or more chronic conditions:
- Alzheimer’s disease and related dementia
- Arthritis (osteoarthritis and rheumatoid)
- Atrial fibrillation
- Autism spectrum disorders
- Cardiovascular disease
- Chronic Obstructive Pulmonary Disease
- Infectious diseases such as HIV/AIDS
- Substance Use Disorders
Developing Comprehensive Care Plans
We devise a comprehensive care plan for all health issues that typically includes some or all of the following elements:
● Problem list
● Expected outcome and prognosis
● Measurable treatment goals
● Symptom management
● Planned interventions and identification of the individuals responsible for each intervention
● Medication management
● Community/social services ordered
● A description of how services of agencies and specialists outside the practice are
● Schedule for periodic review and, when applicable, revision of the care plan
Care Connections: Achieving your goals
Whether that goal is to hold a great grandbaby, travel, having
the energy to take a morning walk, or enjoying the independence of living in your own home longer, your chances of success go up with the
help of a care manager. Ask your doctor if you qualify for this monthly service through Medicare.
Newman Regional Health Medical Partners at the Top of Chronic Disease Management
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. Read More