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Home » Services » Primary Care » Chronic Care Management

Chronic Care Management

Amberwell Atchison

HEALTH COACHING–Chronic Care Management for Medicare Patients

What is Chronic Care Management?

Chronic Care Management is a program for Medicare patients that connects you with a registered nurse who serves as a coach to monitor your chronic condition symptoms, assist with prescription assistance, and assist in making appointments with your doctor. Every month, a nurse will call to review medications and doctors’ appointments as well as discuss things such as falls, vital signs, personal stresses and pain. Chronic care patients are given a phone number to connect with an on-call nurse if there is an emergency or questions after normal business hours. 

Available Programs

  • Heart Failure and Resilience Education 

Stay at Home

You don't have to leave the comfort of your own home! Your health coach will visit with you every month by telephone.

How can a Health Coach help me?

  • Talks with you on the phone about your symptoms
  • Ensures prescriptions are current and that you are taking them properly
  • Coordinates care with other members of your healthcare team like dieticians, specialists, pharmacists, therapists, and dentists
  • Arranges community resources you might need like Meals on Wheels, Home Health, home medical equipment, and public transportation
  • Coordinates testing with other facilities, labs, and radiology
  • Assists you with Medicare, Medicaid, Social Security, Disability, and medication assistance programs
  • Provides regular updates to your primary care provider
  • Provides education about nutrition, your medical conditions, and how to improve your health
  • Answers questions about medications and diet

Examples of Covered Chronic Conditions

  • Chronic heart failure
  • Diabetes
  • COPD
  • Asthma
  • Hypertension
  • Arthritis
  • Thyroid disease
  • Osteopenia/osteoarthritis
  • Dyslipidemia
  • Chronic depression
  • Bipolar
  • Insomnia
  • Anxiety
  • Liver/kidney failure
  • Irregular heart rhythms
  • Stroke

WHO PAYS FOR CHRONIC CARE MANAGEMENT?

The cost of chronic care management services is covered by Medicare. Co-pay may apply. Please note: you have the right to discontinue this service at any time for any reason. Termination will be effective on the last day of the month.

The goal of Amberwell Chronic Care Management is to provide you with the best care possible from everyone involved in your care-to keep you out of the hospital, and to minimize costs and inconvenience to you due to unnecessary visits to doctors, emergency rooms, labs, or hospitals. We know your time and your health is valuable.

Please give this service serious consideration and discuss it with your family and/or caregiver. Your coach will be a helpful and caring advocate for you and your health, while keeping your provider up-to-date.

FOR MORE INFORMATION

To find out more about Amberwell Chronic Care Management, call (913) 674-2299 or (913) 367-2131.

Amberwell Health is an innovative healthcare system with a mission to sustain and strengthen rural healthcare organizations.

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