Population Health Management / Chronic Care Management

Care Coordinator and Transitional Care Management Program

Helping You Manage Your Health

Do you or a loved one need assistance in understanding and managing your chronic disease? Chronic Care Management (CCM) is a whole new approach to health care. It is designed to help you improve your health by simplifying your care and providing increased support to manage two or more chronic conditions.

While patients work with primary care providers to manage medications and therapies, St. Margaret’s Hospital Care Coordinator Program provides additional support at home so that patients can thrive in their homes.

What are Care Coordinators?

Care coordinators help improve the patient’s quality of life by providing tools needed to manage the chronic diseases at home.

The goal of the care coordinator program is to keep patients healthy and at home and provide the support needed to make this happen.

Working with others to enhance wholeness for all those we serve.


Transitional Care and Chronic Care Management Programs:

Our goal at St. Margaret’s Health is to enroll all our Medicare patients in a Chronic Care Management (CCM) Program so that these services will be available to you when you need them.

The Transitional Care Program helps patients transition between a hospital or nursing home and their home. We ensure that you have what you need to return to home. We assist with arrangements for follow-up appointments with the patient’s primary care provider 2-5 days after the patient has been released from the hospital. The Transitional Care Program is designed to help keep patients from being re-admitted. Our team will call the patient each week for a month following discharge and if additional attention is needed beyond that, the patient can stay in the Chronic Care Management Program.

The Chronic Care Management Program (CCM) provides outpatient services for adults who need additional help to navigate their complex health condition(s). They assist in overcoming any barriers the patient may have while managing his or her care and help coordinate with community resources to help patients get the tools they need.

Furthermore, CCM is the care coordination outside of regular office visits for patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation or decompensation or functional decline. It can be delivered to people with many different types of health conditions.

Additionally, CCM is a critical component of primary care that contributes to better outcomes and higher satisfaction for patients. CCM is implemented to help Medicare and dual eligible (Medicare and Medicaid) patients get all the between-appointment help needed to stay on track with their treatments, as well as, plan for better health.

Diabetes management is an important service for our patients and is part of the CCM program. St. Margaret’s has several certified diabetes educators comprised of dietitians, nurses and family nurse practitioners to help our diabetic patients better manage their disease with proper diet, exercise and medications.

Our goal at St. Margaret’s is to help deliver coordinated care that will improve our patients’ health, increase satisfaction with their care and make care more person-centered.

Why is CCM Important?

Patients benefit from enrolling in CCM by:

  • Gaining a team of dedicated health care professionals who can help them plan for better health and stay on track for good health
  • Receiving a comprehensive care plan
  • Getting the support needed between doctor visits
  • Having access to a qualified health care professional 24-hours-a-day, 7 days-a-week

The Goals of the Care Coordinator Program include:

  • Prevention of avoidable hospitalizations
  • Coordination of care between health care providers, patients and caregivers
  • Education of patients and caregivers about the patient’s chronic diseases
  • Ensuring appropriate follow-up with the primary care provider within 7-14 days after the patient leaves the hospital
  • Providing support through frequent contact to the patient and caregivers
  • Addressing any barriers to managing the patient’s diseases at home
  • Connecting patient and caregiver to community resources and/or agencies such as transportation to appointments, home medical equipment, classes, low-cost prescriptions and more
  • Frequent nurse calls to manage laboratory work, such as glucose levels
  • Offering additional services and resources for homebound patients

Payment for CCM:

This is a service paid for by Medicare and your insurance will only be charged for the months that you need
added supportive care by an office nurse or the care coordination team. Copays are usually covered by supplemental insurance.

Your Health Journey

Your Health Journey