Chronic Care Management (CCM) Program at Liberty Regional Medical Center Family Medicine

Medicare beneficiaries with multiple chronic conditions are the highest users of health care services today.  For many physicians, this means hours spent communicating with patients, family members and even other referring physicians outside of the face to face visit with the patient.  The Liberty Regional Medical Center Family Medicine group has implemented a Chronic Care Management Program to assist our Primary Care providers with patients that have 2 or more chronic diseases.  This program will also focus on Annual Wellness Visits for Medicare beneficiaries to ensure preventive measures that will address or identify potential illnesses to avoid escalation to a potential chronic condition.

• Documentation in a certified electronic medical record

• Development of comprehensive, patient centered care plans that will also be shared with the patient

• Minimum of 20 minutes of non-face to face CCM services provided to chronic patient by care team every 30 days

• Enhancement of communication of care team through secure messaging and other secure modalities

• Consistent reconciliation of medication and monitoring adherence of medication compliance24/7 patient access to care team with access to care plan

• Consistent and timely systematic patient assessments

• Better coordination of continuity of care with designated primary care providers or members of care team

• Assistance in management of care transitions among health care facilities, providers and home/community based clinical service providers