This service is monitored by an RN and supervised by an MD.
Patient must have 2 chronic medical conditions.
comprehensive care plan is established, implemented, revised and or monitored.
The CCM helps to facilitate access to
health care services by providing the patient a comprehensive care plan, communication with patient as well as specialists
and hospitals with 24 hour availability. Facilitates appointments and wellness exams. Alerts doctor to issues,
concerns, lab tests, xrays or consultant reports. Medication reconciliation and supervision as needed at least once
per month. Manages care transitions between and among health care providers and settings, including referrals to other clinicians,
follow up after emergency department visits, and follow up after discharges from hospitals, skilled nursing facilities or
other health care facilities. Coordinates with home and community based clinical service providers.
patients with acurate information to help prevent any unnecessary office visits,ER visits or hosptializations..