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Chronic Care Management

What is Chronic Care Management?

If you have two or more chronic conditions, you may feel overwhelmed at the idea of managing your health by yourself. The Chronic Care Management program involves a team of health care professionals working together with your optimum health as the goal.

You deserve proactive care.

The Chronic Care Management program is designed to:

  • Reduce costly emergency room visits.
  • Make you more comfortable when you transition from hospital to home.
  • Lessen the burden of chronic disease in your life.
  • Coordinate the care you need by connecting the health care providers and services that will benefit you and your health.

Most patients who choose to participate in the Chronic Care Management program notice an improvement in their health and overall wellness as a result of the program, including:

  • Better control of chronic illnesses, like diabetes or high blood pressure. Learn more about the Diabetes Self-Management Program.
  • A better understanding of medications and their effects.
  • More cost-effective health care as a result of improved preventative care.
  • Care coordination with the providers on their healthcare team.

How does the Chronic Care Management program work?

Your role in your care

You are in charge of your own healthcare. Your primary contact in the Chronic Care Management program is your Chronic Care Coordinator. Open communication with your Chronic Care Coordinator helps us to know how you are doing and address any issues that may arise.

Your responsibilities as a patient in the CCM program include: 

  • Completing regular check-ins with your Chronic Care Coordinator.
  • Reporting any progress and effects of current medication on a regular basis.
  • Communicating any new symptoms, illness, or concerns you may have right away.

Your Chronic Care Coordinator’s role

You will have a close relationship with your Chronic Care Coordinator who will:

  • Work closely with you and your healthcare team.
  • Be your advisor and educator, helping you understand your medications, diet, activity, and overall lifestyle.
  • Answer questions that will arise.
  • Make sure you have the resources you need.

How do I enroll

Crossing Rivers Health Clinic will answer any questions you may have and enroll you in the program. Once you are enrolled, a registered nurse will review your medical history, and will be well prepared for your first conversation.

Does it cost anything to participate?

Once the patient deductible is met, Medicare Part B covers this service at 80%, just as they would cover any face-to-face visit in the office.

Most supplemental policies cover the remaining cost. For those with participating secondary insurance policies, once the Medicare deductible is met, this program is available at no cost.

Patients without a supplemental policy, or who have a secondary insurance policy that does not cover CCM, would be billed their 20% coinsurance cost.

Chronic Care Management is an approach that is:


A team-based approach, centered around you, ensures that you are in the driver’s seat, making informed decisions that you are happy with.


Your team of clinicians care for your physical and mental health care needs, including prevention and wellness from acute to chronic care.


Your health care team works together for the best results and the best care for you.


There is strong, simple communication between you and your health care team.

Committed to quality and safety

Being highly reliable is at the center of your health care team’s goals. We want to help you make informed decisions about your health.

Talk with the Crossing Rivers Health Clinic team to learn more about how the Chronic Care Management program can help you stay healthier longer, while decreasing your healthcare costs.

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