Chronic Care Management

To enroll in the Chronic Care Management program call 757-505-1853.

Chronic Care Management (CCM) is a Medicare sponsored program that allows us to more closely monitor your health and well being between office visits through monthly phone calls. Participants must be on Medicare and have two or more chronic conditions. Ask staff if you’re eligible to join.

Examples of chronic conditions include, but aren’t limited to:

  • Alzheimer’s disease and related dementia
  • Arthritis (osteoarthritis and rheumatoid)
  • Asthma
  • Atrial fibrillation
  • Autism spectrum disorders
  • Cancer
  • Cardiovascular disease
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Depression
  • Diabetes
  • Hypertension
  • Infectious diseases like HIV and AIDS

What happens after I enroll in the program?

If you consent, or verbally agree, to enroll in the program then you will be contacted monthly by phone by one of our Care Coordinators. Our team consists of RNs, LPNs and Medical Assistants trained to discuss your chronic conditions and treatment as directed by your provider.

Program requirements

  • You agree to the Rural Health Provider providing CCM services to you by verbal consent.
  • You give permission for Eastern Shore Rural Health to share your medical information electronically with other providers to coordinate your care. This is done by granting access to your information in our Electronic Health Record.
  • You acknowledge that only one Healthcare Provider can furnish CCM services to you during a calendar month.
  • You understand that even though CCM services will not involve a face-to-face meeting with your provider, you may be billed a co-pay by Eastern Shore Rural Health for CCM services not covered by your secondary insurance.

Chronic care management includes:

  • Comprehensive Care Plan
  • Direct access to assigned Care Coordinator
  • Medication management
  • Medical services coordination