Program Requirements
Our chronic care management program is designed for individuals with two or more chronic conditions expected to last at least 12 months or until the patient’s death. These conditions should put the patient at significant risk of death, acute exacerbation/decompensation, or functional decline. For Principal Care Management, patients should have a single, high-risk condition.
Comprehensive care plan
Medication management
Preventive care
Care plan sharing
Care coordination
Continuity of care
Care transition management
24/7 access
Resources
Electronic communication options
Electronic health record documentation
Comprehensive assessment
Comprehensive care plan
Medication management
Preventive care
Care plan sharing
Care coordination
Continuity of care
Care transition management
24/7 access
Resources
Electronic communication options