Chronic Care Management

About Chronic Care Management

Pulmonary Associates is pleased to announce the launch of a new program called Chronic Care Management, with the encouragement from Medicare. This program gives Medicare patients and some Medicare replacement patients with two (2) or more chronic illnesses a more personalized and accessible health care plan. This program delivers the coordinated care patients need and deserve; and helps patients stay on track by giving support between office visits.

Our Chronic Care Management program is designed to give patients 24/7 access to medical professionals who are there to help patients live healthier lives with their chronic conditions. Our goal is to improve our patient’s quality of life through better coordination of health care. We will help optimize your medication regimen with lifestyle changes to get you in the best shape possible. While our primary focus is your respiratory status, the Chronic Care team wants to ensure all your chronic conditions are managed effectively. Without optimal lung health, doing simple activities of daily living such as housework, grocery shopping and even dressing can become very difficult and leave you extremely short of breath.

Fifty percent of all adult Americans have at least one serious chronic condition such as Chronic Obstructive Pulmonary Disease (COPD), asthma, pulmonary fibrosis, arthritis, cancer, diabetes, heart disease, sleep apnea, or dementia. But 68% of Medicare beneficiaries have two or more chronic conditions. Therefore, Medicare recognizes the benefit of Chronic Care Management for their beneficiaries. When patients have multiple, often complex, chronic conditions, coordinating services and comprehensively managing the patient’s care is crucial to providing quality health care services. Coordinated care contributes to better health and care for individuals.

If you are interested in this program, feel free to call us any time to discuss at 251-259-5066 or email Chronic Care Management at ccm@lungmds.com

Chronic Care Management Services

• Periodic monthly monitoring to check on your status at home
• Teaching self-assessment strategies and quicker nurse triage for acute flare-ups
• Changing from a reactive healthcare model to a proactive healthcare model
• A personalized plan of care and an Action Plan which includes what to do when you have changes in your health
• 24/7 phone line
• Managing and refilling prescriptions
• Ordering home health services, medical supplies and durable medical equipment as needed
• Coordinating appointments
• Clinical monitoring – provide earlier appointments, if needed
• Answering patient and family questions
• Discussing health improvements and how to handle setbacks
• Fulfilling patient’s health care needs in a timely manner to help prevent exacerbation and the possibility of a hospital admission
• Providing patients with education, self-management skills, and tools needed to become active participants in their own health care
• COPD Toolkit and self-management skills related to living with COPD – The COPD Toolkit provides in-depth education materials, tools, a home exercise program, emergency preparedness plan, traveling with a chronic disease planning and additional resources in a convenient binder to keep all these materials easily accessible and organized

To participate a patient must:

1. Be a Medicare Beneficiary or have a participating Medicare Replacement plans
2. Have at least two (2) chronic conditions, one of which respiratory (a chronic condition is one that is expected to last at least 12 months or for the rest of your life)
3. Consent to participate in the program verbally or in writing
4. Actively participate in the development of a plan of care
5. Provide a date and time in which you will be available to contact by phone/email to provide routine assessments
6. Be responsible for a monthly co-pay which is $10 or less

*Patients may rescind his or her Chronic Care Management consent verbally or in writing at any time, talk to your Pulmonary Provider or nurse about chronic management services and how you might be able to get Chronic Care Management.

Why is Chronic Care Management Needed? 

There is no cure for most respiratory conditions including COPD and asthma, but the good news is that these are manageable conditions. The goal is to keep you strong so that breathing is easier. Oftentimes, there are subtle signals and symptoms that warn of a “flare-up”. We will teach you how to recognize those signs and symptoms so that you can receive the care that you need quickly and prevent that episode from becoming too severe. The goal with this knowledge is to treat “flare-ups” early and effectively prevent hospitalizations.

Managing your health can be challenging, especially if you have two or more chronic conditions or illnesses so Medicare encourages you to take advantage of this service to help you maximize your health and spend more time with your loved ones.

What does Chronic Care Management mean for you? 

1. Having a continuous relationship with a dedicated health care professional who knows you and your history, gives you more personal attention, and helps you make the best choices for your health. This allows you to better manage your care and spend more time focusing on your health.
2. You and your loved ones will have the assistance you need to manage your chronic conditions so you can spend more time doing the things you enjoy. We will keep track of your medical history, medications, and all the doctors you see. You will receive a comprehensive care plan that outlines your treatment plan and goals.
3. Having access to a health care professional 24/7 to address urgent needs from the comfort of your home.
4. Having early interventions to hopefully prevent hospitalizations. If you have Medicare and two or more chronic conditions, talk to your Pulmonary Provider or nurse about chronic management services and how you might be able to get Chronic Care Management or feel free to contact us at any time at 251-259-5066.