Chronic Care Management

Bland County Medical Clinic understands that sometimes managing one’s health can require a little extra assistance.  Our Chronic Care Management program (CCM) is designed to help patients with Medicare who have two or more chronic conditions.  The program is available to patients at both Primary Care locations (Bland County Medical Clinic and Orchard Creek Clinic), and is designed to provide support to patients who need to speak with a nurse several times per month to manage their health.  The CCM program is ideal for the individual who has difficulty managing their medications, coordinating visits with multiple providers, have frequent questions about their medications/health management, or have caregivers who may need assistance.

A care plan will be specifically tailored to each patient and their chronic conditions according to their provider’s recommendations.  Each patient will be provided a copy of this care plan for their review.  The patient’s care plan will be updated approximately every 3 months to reflect their most current health conditions and goals.  Dedicated licensed staff will routinely monitor the patient’s care including but not limited to medications, preventative screenings, follow-ups, coordination of care between specialists, follow-up from hospital stays, ER visits and urgent care visits and ensuring the patient has understanding of their health and treatments.  Chronic Care patients will have direct access to one of our nurse chronic care managers in the office for their needs.

The goal of this program is to optimize the health of our Chronic Care patients, increase their quality of life and prevent hospitalization.

Chronic Care Management can only be provided after the patient’s consent has been obtained.  A verbal authorization will need to be given to one of our chronic care managers.  We may also ask for a signed consent if a co-payment applies to the patient.  Medicare will be billed and if the patient does not have a supplementary coverage, a 20% copay may apply to the patient.  Only one provider can bill Medicare for these services each month.  If the patient is receiving home health, PT/OT in the home, hospice, palliative care or dialysis, the patient will not qualify for this service.  You can also opt-out of this service at any time by notifying their care manager verbally, in writing or through the patient portal.