Chronic Care Management

Value Based Program

Overview

The Chronic Care Management (CCM) program connects patients with chronic conditions to healthcare professionals. This program includes a recording of the patient’s health information and the development of a patient-specific care plan. During monthly interactions, healthcare professionals will review the patient’s active conditions, medications, prognosis, treating physicians and will provide guidance for patients on ways to best cope with their chronic conditions. The healthcare professionals working with patients have a background in nursing, respiratory therapy, nutrition and diabetic counseling, and behavioral health. The goal of the program is to provide better health education and care for patients who suffer from chronic conditions.

Eligible Patients

Patients with at least 2 of the following conditions are eligible for the CCM Program:

• Asthma
• Atrial Fibrillation
• Bipolar Disorder
• Cancer
• Kidney Disease
• Dementia
• Depression
• Diabetes
• Chronic Heart Failure
• Hyperlipidemia
• Hypertension
• Heart Disease
• Osteoarthritis
• Rheumatoid Arthritis
• Stroke

Chronic Care Management Team

Referring Physician:

Your PCP or specialist must refer you into the program. They will receive a monthly care plan with updates on how your progress.

Health Coach:

Healthcare professional that will contact you at least one time per month via phone. The individual may be a nurse, respiratory therapist, nutritionist, or diabetic educator depending on what would best benefit you.

Coverage

Medicare, some PPO w/copay or coinsurance
CPT codes: 99490, 99491, 99487

Questions

If you would like to learn more about the RPM program or see if you are eligible for it, please contact Max Briles at (949) 443-4303 x 134 or This email address is being protected from spambots. You need JavaScript enabled to view it.