Chronic Care Management

What You Need to Know

What is chronic care management?

Chronic care management (also called CCM) is a level of extra support that we offer to
our patients who have two or more chronic medical conditions. Our practice’s CCM
program can help you be as healthy as possible. It gives you access to the resources
and guidance you need to manage your chronic conditions effectively.

Under our practice’s CCM program, we will typically spend at least 20 minutes, at least
quarterly, coordinating care for your chronic conditions. Some patients may require
more time, some less.

This includes coordination of the health care you get from us, as well as the care you
may get at another doctor’s office, at the hospital, at the pharmacy, at your home, or
from a community service organization. If your chronic conditions require more intensive management and we spend 60 minutes or more per month coordinating your care, that is considered complex CCM. However, most patients do not need complex CCM services on a regular basis.

Who will be enrolled?

All patients at Bridge Primary with Medicare will be enrolled in our CCM program, with
consent. This will allow us to provide a higher level of care to all patients.

What is a chronic condition?

A chronic condition is a health problem that can be controlled with proper treatment but not cured. For example, diabetes, high blood pressure, and chronic obstructive
pulmonary disorder (COPD) are chronic conditions.

What are the benefits of signing up for this program?

When you sign up for our CCM program, a dedicated care team from our practice will
coordinate all of your health care. Although each patient is different, many patients who get CCM services can avoid expensive emergency department visits and hospital
admissions.

Other benefits of signing up for the program include the following:

• We will work with you to create a personalized care plan that includes your
  health goals and specific action steps to meet them. We will also update your
  plan as necessary.
• We will give you extra support outside of office visits.
• A member of your care team will be accessible to you 24 hours a day, 7 days a
  week to address your urgent care needs so that you can get this care regardless
  of the time of day or day of the week.
• You will always be able to schedule routine appointments with a designated
  member of your care team.
• We will schedule any preventive care that you need. For example, we will be
  sure that you get the flu vaccine at the right time every year.
• We will help you manage your medicines.
• We will coordinate the health care you get from us, as well as the care you may
  get at another doctor’s office, at the hospital, at the pharmacy, at your home, or
  from a community service organization.

Do I have to pay for CCM services?

These services are covered by Medicare Part B. They are subject to the usual Medicare
deductible and coinsurance. Our office will collect a copay for each month in which you
get qualifying CCM services. Please note that if you don’t get qualifying CCM services
in a certain month, we will not bill you for that month. After the Medicare deductible has been met, most patients pay approximately $8 to $18 to coordinate their care during the month. If you have supplemental insurance, it may cover all or part of the copay
amount. Check with your insurance carrier for details.

Can I stop getting CCM services?

Yes. You can cancel CCM services at any time in writing or verbally (for example, by
calling our office or by telling a member of your care team). All care from our office must take place during an appointment if you are not participating.