Chronic Care Management
Between-visit support for patients living with kidney disease and other chronic conditions
What is Chronic Care Management?
Chronic Care Management (CCM) is a Medicare program that supports patients with two or more chronic medical conditions. For our nephrology patients, CCM provides coordination services to help manage conditions like chronic kidney disease (CKD), hypertension, diabetes, anemia, and other kidney-related health issues. Our goal is to help you stay on track with your treatment plan, delay CKD progression, avoid hospitalizations and maintain your quality of life.
What Services Are Included in Our Connected Care CCM Program?
The Connected Care CCM program at Metrolina Nephrology Associates is staffed by Charlotte-based Care Managers who support your health with a variety of services, including:
• Personalized Care Plans: We work with you and your provider to create a customized CKD care plan that addresses your specific conditions, treatment goals, medication management, and lifestyle needs. This plan is regularly updated to reflect your progress and changing needs.
• Care Coordination: We coordinate with your other healthcare providers, including pharmacies, transplant teams, and specialists outside of Metrolina Nephrology. We provide follow-up support after hospital stays to prevent readmissions.
• Medication Management: Our team assists with prescription refills, medication adjustments based on kidney function, and CKD education to help you understand your medications. Medication assistance programs are available to those who qualify.
• Patient Education: We empower you with resources and guidance on managing your chronic conditions, including dialysis options and strategies to prevent CKD progression.
• Appointment Assistance: We help schedule and remind you of appointments with your nephrologist or other specialists to keep your care on track.
• 24/7 Access to Care: Our patients have round-the-clock access to Metrolina Nephrology providers through our after-hours care line, ensuring you can get help with urgent medical needs at any time.
• Proactive Outreach: Our text-based Connected Care platform helps you communicate with our team at your convenience, anywhere you go! We reach out weekly to share health tips and see how you are doing, and you can contact your Care Manager with the touch of a button.
These services are designed to complement your regular in-person visits, providing ongoing support to help you manage your kidney health and related conditions.
Who is Eligible for Chronic Care Management?
To qualify for a CCM program, you must meet the following criteria:
• Multiple Chronic Conditions: Medicare patients with two or more chronic conditions may qualify. A chronic condition is expected to last at least 12 months. Common qualifying conditions in our nephrology practice include:
- o Chronic kidney disease (CKD)
- o Hypertension
- o Diabetes
- o Anemia
- o Metabolic bone disease
- o Other related conditions (your provider can confirm eligibility).
• Consent: You must provide written consent to participate in the CCM program. First, we will explain the program, including any cost-sharing responsibilities. You may have a copay for this service. If CCM is a good fit for you, we will then document your agreement to enroll. You can unenroll at any time.
• Initiating Visit: An in-person visit with one of our nephrology providers is required to start CCM services. If you’ve been seen by our practice within the past 12 months, this requirement may already be met.
How Much Will This Cost?
Chronic Care Management is covered by Medicare. While there may be a small cost sharing payment (copay) depending on your insurance plan, Connected Care can save you hundreds of dollars by preventing unnecessary hospital visits. You may opt out of the program at any time.