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 healthcare plan.  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 66% of Medicare beneficiaries have two or more chronic conditions.  This is why 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 are crucial to providing quality health care services.  Coordinated care contributes to better health and care for individuals.  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 a more healthy life with their chronic conditions. Our ultimate goal is to keep you as healthy as possible for as long as possible. 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 of your chronic conditions are managed effectively. Without optimal lung health, doing simple activities of daily living such as housework, grocery shopping and even dressing yourself can become very difficult and leave you extremely short of breath.

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
  • 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 healthcare 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 healthcare
  • 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:

  • Be a Medicare Beneficiary or have a participating Medicare Replacement plans
  • 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 live)
  • Consent to participate in the program verbally or in writing
  • Actively participate in the development of a plan of care
  • Provide a date and time in which you will be available to contact by phone/email to provide routine assessments
  • 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

Who We Are:

Our Chronic Care Management Team is led by a Nationally Certified Adult Acute and Critical Care Clinical Nurse Specialist. Our Chronic Care Management Team is led by a Masters prepared Nurse Educator with a long history of working with patients living with respiratory conditions. We are available 24/7 to help meet your healthcare needs and create a personalized care plan.  This program will give you the resources you need to successfully live with your Chronic Obstructive Pulmonary Disease.

Why is Chronic Care Management Needed?

As stated before, there is no cure 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.  Often times 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 preventing hospitalizations.

We will refer you for Pulmonary Rehab program every 18 months.  This outpatient program will teach you exercises to help keep your muscles in shape.  The program will also offer additional education that will help you breathe correctly, learn more about your medications and the proper way to use your inhalers.  Pulmonary Rehab also monitors your oxygen level while you are exercising to make sure that you have an adequate level of oxygen in your body as you exert yourself.  You will also have in your toolkit a set of exercises to do at home once you have completed your Pulmonary Rehab classes to ensure that your muscles stay strong.

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 healthcare 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.