Chronic Condition Management
Patients with multiple chronic conditions* are more likely to be hospitalized and have restrictions on their ability to work and engage in daily tasks.
Our team recognizes that for patients with two or more chronic conditions, a little extra attention can go a long way. This means better management of their health care needs, helping stay healthier without extra office visits. This could mean the difference between a weekend at home with family or hours spent in the emergency room.
Avance Care’s Chronic Condition Management service is designed to meet Centers of Medicare and Medicaid Services Chronic Care Management (CCM) program. It includes a minimum of 20-minutes of non-face-to-face time per month with patients in coordinating care, medication management, and much more.
What This Means to You as a Patient
Ongoing chart review to identify issues that should be discussed and addressed
Ensure medications are working and assistance to keep track of which medications to take and when
Coordinated care between specialists, testing centers, and hospitals to make sure everyone is working together
Assistance in making follow-up appointments and appointments with specialists
Monthly check-in, more personalized attention to patient and their health management goals
We are always available to answer any questions
*Chronic conditions include but not limited to diabetes, hypertension, cancer, COPD, Cardia conditions (CHF, Cardiomyopathy, CAD), asthma, arthritis, renal failure, etc.
How It Works
Our care team will call you once a month at a minimum. We discuss your current plan of care, any problems or concerns you have, and difficulties you may be facing with your health goals and treatment. You will receive a written care plan with goals for your health at least once a month.
Chronic Care Management can lower your out-of-pocket costs, helping you save money by visiting the office less often and enjoying better health.
Who is Eligible?
Any person enrolled in Medicare or Medicare Advantage who has two or more chronic conditions can participate. Example conditions include diabetes, hypertension, cancer, COPD, Cardiac conditions (CHF, Cardiomyopathy, CAD), asthma, arthritis, renal failure, etc.
The small number of patients who do not have a secondary insurance or a Medicare Advantage plan may incur coinsurance similar to other Medicare services at approximately $8 per month.
Transitional Case Management
The Transitional Case Management (TCM) program supports members in transition from an inpatient setting to a home setting. In an effort to prevent avoidable readmissions, TCM consists of discharge follow-up and case management. The TCM team works closely with members and their physicians to support and reinforce treatment plans, emphasizing symptom management and patient empowerment. TCM team may include Registered Nurse, Clinical Pharmacist, Dietitian, Behavioral Therapists, and others as needed.
Members are often automatically enrolled in the TCM program upon hospitalization.
Discharge follow-up calls are made to assist the member with:
- Treatment plan adherence
- Medication adherence
- Physician follow-up
- Disease process education
- Caregiver availability information
- Homecare evaluation and resources
- Referrals to other Case Management/Disease Management programs
At the core of these programs is health education as well as a focus on self-care, close follow-up with the treating physician and medication management. Participants have access to information and resources that focus on education, prevention and health reminders.