Chronic Care Management

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Patients with multiple chronic conditions can easily get off track in their care. Disruptions in routines, decreased access to care, or delays in medication refills can quickly escalate to acute exacerbations in previously stable conditions. By enrolling in Summit Medical Consultants, Chronic Care management (CCM) Program, our Care Team can help patients get the care they need between provider visits. 

Who qualifies for CCM? 

 

Any Medicare Beneficiary with two or more chronic conditions that are expected to last more than 12 months or that place the patient at significant risk for acute exacerbation or functional decline.

Comprehensive Care Plans 

 

Our Comprehensive Care Plans are individualized for each patient and include the following components:

  • Problem list;

  • Expected outcome and prognosis;

  • Measurable treatment goals;

  • Symptom Management;

  • Planned interventions, including all preventive care services;

  • Medication Management Monthly Follow-Up

 

Our team of Care Management Coordinators will follow up with you or your caregiver monthly to review your individualized Care Plan.