Understanding Chronic Care Management: Coordinated Support for Ongoing Conditions

For patients living with ongoing health conditions, consistent medical support can make all the difference. Chronic Care Management, often referred to as CCM, provides patients with coordinated care between regular appointments. At Lane Family Practice, this program enables patients to manage their conditions more effectively, ultimately improving their long-term health and quality of life.

What Is Chronic Care Management and How Does It Work?

Chronic Care Management is a Medicare-designed program that supports patients with two or more chronic conditions, such as diabetes, hypertension, heart disease, asthma, or arthritis. It connects patients to a dedicated healthcare team that helps track progress, manage medications, and provide ongoing communication between office visits.

Each month, patients receive personalized care coordination from a nurse navigator assigned to their care team. This support can include phone check-ins, face-to-face visits for education or during clinic appointments, updates to care plans, and guidance on lifestyle changes that reduce the risk of complications. The goal is to prevent unnecessary hospitalizations and emergency room visits by keeping patients engaged in their health throughout the year.

The Benefits of Chronic Care Management for Patients

Managing a chronic condition often requires input from multiple healthcare providers, various medications, and tailored treatment plans. Chronic Care Management simplifies this process through communication and continuity. Patients benefit from:

• A personalized care plan developed by their Lane Family Practice team
• 24/7 access to a healthcare professional for urgent needs
• Monthly follow-ups to monitor progress and adjust treatment plans
• Guidance on medication management and preventive care

This consistent support helps patients stay on track, better understand their conditions, and maintain stronger overall health.

Who Qualifies for Chronic Care Management at Lane Regional Medical Center

Patients may qualify for Chronic Care Management if they are traditional Medicare beneficiaries who receive care through Lane Family Practice and have two or more chronic conditions expected to last at least 12 months. Medicare allows enrollment in only one CCM program at a time, so Lane providers encourage eligible patients to enroll in the clinic’s program rather than a specialist’s. This ensures a holistic, whole-patient approach rather than care focused on a single diagnosis. The program also offers regular communication and support between office visits to make managing chronic conditions easier.

As a Medicare cost-sharing program, standard deductibles and copays may apply. Many secondary insurance providers help cover these costs, but patients should confirm their coverage before enrolling.

Chronic Care Management and Support for Zachary Patients

Through Lane Regional Medical Center’s coordinated care network, Lane Family Practice offers patients long-term support to manage chronic health conditions with confidence. Since its inception in 2017, the program has provided hundreds of patients with personalized care plans, monthly follow-ups, and direct access to healthcare professionals, helping to reduce hospital visits and improve daily quality of life.

By combining the expertise of Lane Family Practice with the full resources of Lane Regional Medical Center, patients in Zachary receive the continuous, compassionate care they need to stay healthier and more independent every day.