Empowering Better Health for Patients with Chronic Conditions
Chronic Care Management (CCM)
Empowering Better Health for Patients with Chronic Conditions
At MEDHELP, we are dedicated to improving the lives of individuals living with chronic illnesses. Our Chronic Care Management (CCM) program supports patients who have two or more chronic conditions, offering comprehensive, personalized care beyond traditional office visits.
Through CCM, patients gain access to ongoing support services including:
- Customized Care Planning
- Medication Management
- Coordination with Specialists & Other Providers
- Remote Monitoring for Early Intervention
- Education & Coaching to Encourage Healthier Living
Our experienced clinical team in the United States works closely with patients facing chronic conditions such as arthritis, asthma, atrial fibrillation, hypertension, hypotension, obesity, cancer, cardiovascular disease, COPD, and diabetes.
How Our CCM Team Helps
Our dedicated Care Team Members (CTMs) maintain regular contact with each patient to help manage chronic conditions effectively. Services include:
Personalized Care Plans – Tailored to the patient’s unique health needs and goals.
Remote Patient Monitoring (RPM) – Optional technology for real-time health tracking.
Proactive Health Management – Addressing issues before they become urgent.
Patient Education – Empowering patients to take control of their health.
Resource Optimization – Helping reduce hospitalizations and emergency visits.
Improved Health Outcomes – Focusing on better quality of life and well-being.
Key Steps in CCM Enrollment
Consent Calls
Our remote onboarding team connects with patients to:
Explain how CCM works and benefits them
Discuss responsibilities, including costs like copays or coinsurance
Schedule a 30-minute welcome call once the patient consents
Welcome Calls
During the welcome call, CTMs:
Review the patient’s individualized care plan
Set monthly check-in appointments
Help establish health goals
Keep in touch between calls as needed
What’s Included in a CCM Care Plan?
Each care plan is carefully crafted to support patient well-being and includes:
A Problem List summarizing chronic conditions
Clear Expected Outcomes & Prognosis
Measurable Treatment Goals
Cognitive and functional assessments
Symptom and medical management strategies
Evaluation of the patient’s environment and support systems
Our goal: better care, greater patient satisfaction, and healthier outcomes.
Resources
We have many resources to assist you – below are a few links to RPM, CCM, and Optimize Health Content
● 2025 Remote Care Guide
● RPM Buyers Guide
● RPM Onboarding Best Practices Guide
● Why CCM is the Perfect Compliment to RPM
● RPM and CCM Fact Sheet
● Case Study: From Paper to Remote Patient Monitoring
● Case Study: Reducing Hospitalizations and the Effects of Chronic Kidney Disease with RPM
● Case Study: Lake Oconee – A Rural Community Practice
● Case Study: Accelerating Excellent Care at Christine Meyer, MD and Associates
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