What is Care Management? 

At CVH/SMH, nurse care managers partner one-on-one with patients, family/friend supports, and providers to help achieve wellness through assessment, planning, education, resource management, and service connection. Based on your needs and values and, in collaboration with providers, the care manager links individuals with appropriate resources to achieve optimum value and desired outcomes. 

Chronic Care Management (CCM): Monthly ongoing telephonic support for individuals with two or more chronic illnesses expected to last at least 12 months.  Chronic health conditions place individuals at significant risk of death, acute exacerbation/decompensation, or functional decline. Through personalized assessment and care plan development, ongoing support is provided to patients to live well with their health conditions.  CCM routinely focuses on social, medical, financial, and behavioral issues associated with complex care needs. Medicare recognizes “CCM as a critical primary care service that contributes to better Medicare patient health and care.”   

Transitional Care Management: Telephonic one-on-one support for times of transition home after hospitalization or emergency room visits. Within two days of discharge, a TCM nurse care manager contacts patients to ensure a seamless transition after discharge and coordinates appropriate referrals as recommended.  Medications and/or recommendations are reviewed to minimize potential errors or confusion.

You may benefit if you:

  • Had multiple Emergency Room visits in last year
  • Desire support to improve your quality of life.
  • Have Medicare or dual eligibility (Medicare and Medicaid) and live with two or more chronic conditions. For example: arthritis, cancer, depression, diabetes, and high blood pressure.
  • Are at significant risk of death, acute exacerbation, or functional decline

Professional case managers are uniquely qualified to help close gaps in care and work collaboratively to advocate, communicate and manage resources for higher quality, cost-effective care.   We invite you to reach out to our Care Management team for support. Ask your provider about care management, or call your clinic and ask to speak to a nurse care manager.

Sources: 

WHAT IS CHRONIC CARE MANAGEMENT? (cms.gov)

FAQ About Case Management | Commission for Case Manager Certification (CCMC) (ccmcertification.org)