What is Chronic Care Management?


October 29, 2020

Earlier this year Columbia Family and Waitsburg Clinic launched a new program called Chronic Care Management. This program is a model of care designed to improve your overall health by assisting you in the coordination of care and health management. If you suffer from two or more chronic conditions (i.e.: Diabetes, chronic pain, Hypertension, Congestive Heart Failure, COPD) and have Medicare Part B you may qualify. Our goal through this program is to provide you with the best possible care, keep you out of the hospital, and minimize costs and inconvenience to you due to unnecessary visits to doctors, emergency rooms, labs or hospitals.

What does this mean for you? It means you’ll have access to your own nurse who will assist you across the healthcare spectrum! Your care will be overseen by your primary care provider at all times.

The benefits of the program include:

•Develop a comprehensive care plan that is specific to you and your health concerns. This care plan with be reviewed monthly and updated as needed.

•Assistance in coordinating care between your PCP and specialists. This assists in continuity of care and ensures your PCP has consult notes from specialists.

•Prompt access to your PCP when needed.

•Assistance in accessing community support systems and navigating Medicare.

•Transitional care management between hospital and home if needed. This ensures you are seen by your provider in a timely manner after your discharge.

•Access to an RN to answer questions or concerns 24 hours, seven days per week.

•Assistance in managing your medications and access to a pharmacist who will review your and answer any questions you may have about your medications.

•Coordination of preventative care services such as mammograms, colonoscopies, immunizations, and other cancer screenings.

We believe that to achieve your healthcare goals there must be a partnership between the patient and their medical provider. By remaining involved in the decisions regarding your health, health care and lifestyle, we can develop a stronger relationship with you.

If you feel you may qualify for the Chronic Care Management program, and are interested or have any questions please call 509-382-3216

Submitted by Melissa Nesje, Population Health RN, Columbia County Health System


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