Call Nephrology Associates at 251-415-4458 to learn more about Chronic Care Management (CCM) or check your eligibility.
What is Chronic Care Management (CCM)?
Chronic Care Management (CCM) is a Medicare program that supports patients with two or more chronic conditions by providing care coordination services via telephone. For our nephrology patients, this means tailored assistance to manage conditions like chronic kidney disease (CKD), hypertension, diabetes, anemia, and other kidney related comorbidities. Our goal is to help you stay on track with your treatment plan, delay the progression of your kidney disease, avoid complications, hospitalizations and maintain your quality of life.
Services Available Through Our CCM Program
Our CCM program offers a comprehensive suite of services to support your health, including:
- Personalized Care Plans: We work with you to create a customized care plan that addresses your specific conditions, treatment goals, medication management, and lifestyle needs. This plan is regularly updated to reflect your progress and changing needs.
- 24/7 Access to Care: Our patients have round-the-clock access to our dedicated care team through our 24/7 Nursing Line, ensuring you can get help with urgent medical needs at any time.
- Care Coordination: We coordinate with your other healthcare providers, including specialists, dialysis centers, pharmacies, and transplant teams, to ensure seamless care across all settings.
- Medication Management: Our team assists with prescription refills, medication adjustments based on kidney function, and education to help you understand your medications. Medication assistance programs are available to those who qualify.
- Support for Transitions of Care: We provide follow-up support after hospital stays or other care transitions to ensure continuity and prevent readmissions.
- Patient Education: We empower you with resources and guidance on managing your chronic condition, including nutrition education by our registered dietician, dialysis planning and options and strategies to prevent disease progression.
- Appointment Assistance: We help schedule and remind you of appointments with your nephrologist or other specialists to keep your care on track.
These services are designed to complement your regular in-person visits, providing ongoing support to help you manage your kidney health and related conditions.
Eligibility Requirements for CCM
To qualify for our CCM program, you must meet the following criteria:
- Multiple Chronic Conditions: You must have two or more chronic conditions expected to last at least 12 months or for the rest of your life. Common qualifying conditions in our nephrology practice include:
- Chronic kidney disease (CKD)
- Hypertension
- Diabetes
- Anemia
- End-stage renal disease (ESRD)
- Metabolic bone disease
- Other related conditions (your provider can confirm eligibility).
- Consent: You must provide verbal or written consent to participate in the CCM program. During an initiating visit, we will explain the program, including any cost-sharing responsibilities, and document your agreement to enroll.
- Initiating Visit: An in-person visit, such as an Annual Wellness Visit (AWV), Initial Preventive Physical Exam (IPPE), or other face-to-face evaluation with one of our providers, is required to start CCM services. If you’ve been seen by our practice within the past 12 months, this requirement may already be met.
To learn more or check your eligibility, call us at 251-415-4458 or ask your nephrologist at your next appointment. You can un-enroll from the CCM program at any time if needed.