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Happy Costumers
Chronic Care Management is a Medicare-covered program that provides ongoing, between-visit
support for patients living with two or more chronic health conditions. Unlike a standard office visit that
addresses one concern at a time, CCM takes a big-picture approach — ensuring that all of your
conditions, medications, specialists, and day-to-day health needs are coordinated under one proactive
care plan.
For seniors managing a combination of conditions like diabetes and hypertension, or COPD and heart
failure, the complexity of juggling multiple medications, provider appointments, and lifestyle changes
can become overwhelming. That is exactly where CCM fills the gap.
At 1st Care Management, our chronic care team provides consistent oversight, patient education, and
ongoing communication with your entire care network — keeping you informed, supported, and out of
the hospital.
What Does Our Chronic Care Management Program Include?
Our care coordination team reaches out to you by phone, email, or face-to-face visit within two business days of your discharge. This initial contact confirms your discharge instructions, identifies immediate concerns, and begins the transition process
A licensed nurse practitioner visits you at home to conduct a comprehensive assessment — reviewing
your current health status, evaluating your home environment for safety risks, reconciling all medications, and updating your care plan. Every visit is supervised by a board-qualified physician.
Between your discharge and your scheduled home visit, our team works behind the scenes to keep
your recovery on track. This includes communication with your hospital care team and specialists, education on self-management and activities of daily living, medication management assessment and
treatment follow-through, identification of community health resources that benefit your recovery, and an assessment of ongoing care and services you may need.
TCM is available to patients transitioning from an inpatient facility back into a community setting. If you or a loved one has recently been discharged from any of the following, you may be eligible.
Happy Costumers
Chronic care management (CCM) is a Medicare-covered program that provides ongoing monitoring, education, and care coordination for patients with two or more chronic health conditions.
If you have been diagnosed with two or more chronic conditions — such as diabetes, hypertension, heart disease, COPD, or arthritis — you likely qualify. Contact us to confirm eligibility.
Yes. Medicare Part B covers CCM services. A small copay or coinsurance may apply depending on your plan. We can verify your coverage before enrollment.
CCM patients receive regular check-ins — typically at least once per month — with additional outreach as needed based on your care plan and current health status.
Absolutely. We encourage family members and caregivers to participate in care planning, education sessions, and check-in calls.
Ask us your questions directly to get clear and concise answers to your questions about home care and personalised nursing. Let us guide you through your options.
