Chronic Care Management

Chronic Care Management

Chronic Care Management

Technology driven tools/resources are utilized to integrate the interaction between patients and care-givers to maximize patients’ health needs.

Billable non face-to-face care coordination services for Medicare patients with two or more chronic conditions.

  • AHC’s trained and licensed staff call patients that have two or more chronic diseases. We build a supportive relationship with patients and their care-givers while providing care coordination support that will ensure appropriate services for the patients’ health needs. Changes in patient symptoms, or behavior are monitored and reported; any significant patient concerns, along with any other patient status updates are communicated to the Primary Care Physician. A comprehensive care plan is created and maintained during the duration of the service.

By providing a 24-hour-a-day, 7-day-a-week seamless extension of internal staff will result in improved communications between the patient and caregiver regarding the prescribed care plan. CCM can be implemented utilizing the telephone, secure messaging, secure Internet, or other asynchronous non-face-to-face consultation methods such as: e-mail, or a provider based secure electronic patient portal.