Chronic Care Management
Chronic Care Management
Better Care Between Office Visits: Expert Support for Chronic Disease Management
Chronic Care Management (CCM) empowers patients with ongoing conditions to stay healthier and more informed—between visits. Through GMC’s CCM services, eligible patients receive proactive, personalized care coordination designed to improve outcomes and reduce hospitalizations.
Insurance-Friendly, Fully Compliant
CCM is covered by Medicare and many private insurers.
Who's Eligible?
- Two or more chronic conditions (expected to last 12+ months)
- Conditions must place the patient at risk for functional decline
- Must consent to CCM services
- Available to Medicare and many private plan enrollees
What We Provide: Proactive, Personalized Management
- Structured recording of patient health information
- Maintenance of comprehensive, electronic care plans
- Coordination of care transitions (e.g., post-discharge follow-up)
- 24/7 patient access to clinical support and health data
- Timely communication of health information across care teams
- Ongoing support in achieving patient-specific health goals
All services are directed by the patient’s primary provider and supported by our experienced care management team.
What Makes CCM Unique?
- Care provided outside of face-to-face visits
- Continuous relationship with a designated care team member
- Emphasis on preventive care and health goal achievement
- Engagement with both patients and caregivers
- Real-time updates and information sharing
Examples of chronic conditions include, but are not limited to:
- Alzheimer's Disease and Related Dementia
- Arthritis
- Asthma
- Atrial Fibrillation
- Autism Spectrum Disorders
- Cancer
- Cardiovascular Disease
- Chronic Obstructive Pulmonary Disease
- Depression
- Diabetes
- Hypertension (High Blood Pressure)
- Infectious Diseases such as HIV/AIDS
- Lupus
- Multiple Sclerosis
- Sleep Apnea
Patients must have a primary care provider at Gabert Clinic and be enrolled in Medicare and meet the program’s health criteria.
How to Get Started
- Provider Referral – CCM requires a provider referral to initiate.
- Eligibility Review – We verify qualifying conditions and coverage.
- Plan Development – A personalized care plan is created and reviewed with you.
- Monthly Monitoring – Regular contact, progress tracking, and reporting.
- Ongoing Collaboration – Stay connected with timely updates on patient status.
For more information contact:
Wendy Mintz Population Health Nurse Director 406-345-3396 wmintz@gmc.orgThe Centers for Medicare & Medicaid Services (CMS) recognizes Chronic Care Management (CCM) as a critical component of primary care that contributes to better health and care for individuals.