Chronic Care Management
At c-lynx, we are dedicated to providing comprehensive care and support for individuals with chronic conditions. Our team of healthcare professionals is committed to improving the quality of life for patients by implementing personalized care plans, remote monitoring, and education. Discover how our Chronic Care Management services can make a positive impact on your health journey.
Requirements for Chronic Care Management
Medicare Patient (65+)
2+ Chronic Conditions expected to last more than 12 months
Patient Consent
Goals and Challenges of Chronic Care Management:
- Dramatically lower the cost of care
- Reduce visits to the physician’s office and hospital
- Encourage patients to take greater control of their health
- Offer direct, 24-hour contact with an integrated CCM team
- Increase convenience, comfort, and quality of life for patients
- Allow the care team to stay informed about the patient’s medical status
Here's an overview of the extensive services typically included in Chronic Care Management:
Structured Recording of Patient Health Information:
Systematic documentation of relevant health information, ensuring a comprehensive understanding of the patient’s medical history, current conditions, and treatment plans.
Keeping Comprehensive Electronic Care Plans:
Development and maintenance of electronic care plans tailored to each patient’s specific needs. These plans serve as a roadmap for managing chronic conditions and achieving health goals.
Managing Care Transitions and Other Care Management Services:
Assistance in navigating care transitions, such as hospital discharges or transitions between healthcare providers. Additionally, other care management services may include coordinating appointments, referrals, and ancillary services.
Coordinating and Sharing Patient Health Information Promptly:
Coordination of patient health information sharing within and outside the practice. This involves ensuring that relevant healthcare providers have timely access to patient data to facilitate informed decision-making.
Continuous Patient Relationship with Chosen Care Team Member:
Facilitating a continuous and ongoing relationship between the patient and a designated member of the care team. This personalized connection enhances communication and fosters a sense of trust and continuity in care.
Supporting Patients with Chronic Diseases in Achieving Health Goals:
Providing support and guidance to patients with chronic diseases in setting and achieving health goals. This involves collaborative efforts to improve lifestyle choices, manage medications, and address specific health objectives.
24/7 Patient Access to Care and Health Information:
Offering patients round-the-clock access to care and health information. This accessibility ensures that patients can reach out for assistance or information whenever needed, contributing to proactive and continuous care.
By incorporating these services, c-lynx aims to go beyond traditional episodic care and create a more comprehensive, patient-centered approach. This approach is particularly beneficial for individuals managing chronic conditions, fostering better health outcomes and improved quality of life.
The list of covered conditions for Chronic Care Management includes:
- Alzheimer’s disease and related dementia
- Arthritis (osteoarthritis and rheumatoid)
- Asthma Atrial fibrillation
- Autism spectrum disorders
- Cancer
- Cardiovascular disease
- Chronic obstructive pulmonary disease (COPD)
- Depression
- Diabetes
- Hypertension
- Infectious diseases such as HIV/AIDS
- Substance use disorders
