Chronic Care Management (CCM)

Chronic Care Management (CCM) is one of the four components of value-based care. It works with individuals with multiple chronic conditions, including diabetes, heart disease, arthritis, COPD, and others, to integrate them with consistent and team-based care. This federally recognized program assists patients in reducing inpatient visits, safely managing medications, and receiving coordinated care designed for their specific needs.

What is Chronic Care Management (CCM)?

CCM services are for patients with two or more chronic illnesses. Unlike traditional care, CCM delivers medication and preventive care through a dedicated care team coordinating all appointments across disconnected providers.

Our collaboration with Medicare rigorously approves CCM providers to ensure patients receive 24/7 support, whether adjusting treatment plans, addressing sudden symptoms, or answering questions after hours. This program prioritizes long-term wellness over-reactive care, helping individuals avoid emergencies and focus on daily quality of life.

Delivering Exceptional CCM

AZZ Medical Associates combines Medicare’s evidence-based guidelines with personalized care plans. Here’s how we stand out:

Proactive Health Tracking & Coordination

Our providers use secure, real-time technology to track medications, symptoms, and health goals. We coordinate with specialists, pharmacies, and caregivers to ensure everyone is aligned so patients do not have to repeat their stories or worry about gaps in care.

Your Custom Care Plan

Every patient receives a comprehensive care plan fit for their needs, including:

Clear, measurable goals (e.g., lowering blood pressure or improving mobility).
Medication reviews to avoid harmful interactions.
Preventive care reminders (like flu shots or screenings).
Secure 24/7 access to your care team via phone or patient portal (EHR).

We focus on long-term care management to prevent minor issues from becoming emergencies, helping you avoid chronic diseases.

Who Qualifies for Chronic Care Management?

To be eligible for Medicare-covered or other qualified insurance CCM services, healthcare recipients must have two or more chronic conditions that affect their ability to function in their daily lives. These conditions must be expected to last at least 12 months or pose significant health risks.

Conditions We Manage

Our team specializes in:

Common chronic illnesses: Diabetes, hypertension, COPD, arthritis, and more.
Complex conditions: Alzheimer’s, cancer recovery, atrial fibrillation, and more.
Mental health: Depression, anxiety, substance use disorders, and more.
Secure 24/7 access to your care team via phone or patient portal (EHR).

Medicare often covers CCM at minimal cost, making it easier to access the personalized healthcare solutions you deserve.

Chronic Care Management Breakdown

Consent & Collaboration

We explain everything clearly (including any costs the patient might owe) before enrolling in CCM so there is no confusion. Before moving forward, we ask for consent to ensure patients are comfortable and fully understand how CCM works. There will be no surprises, no fine print, just honest conversations about patient-centered care.

Your Digital Care Hub

All the health details, including medication management, lab results, and provider notes, are stored in one secure online profile (EHR). Our primary care team and approved specialists (like the rheumatologist or pulmonologist) can view updates instantly. This means fewer phone calls, no repeating your story, and everyone stays on the same page.

Monthly Check-Ins & Crisis Prevention

Our providers' team reviews your health data monthly, looking for patterns and probable health concerns. For example, if your blood sugar spikes repeatedly, we will adjust a personalized treatment plan before it leads to a hospital trip. It is like having a safety net that catches brief issues early so they do not turn into critical concerns.

Why Our CCM Program Stands Out

Medicare-Approved, Patient-Trusted

Our Value-Based Care adheres to strict CMS guidelines, meaning every care plan is grounded in evidence-based practices that slow conditions like diabetes progression or COPD flare-ups. Medicare's thorough monitoring ensures patients receive safe and effective care.

Care Without Barriers

Geography, language, or income should not block access to integrated healthcare. AZZ Medical partners with local authorities to address challenges like transportation shortages offers bilingual care coordinators, and helps patients navigate financial assistance programs. Telehealth bridges the distance for rural patients (because managing chronic conditions should not depend on ZIP code).

Ready to Take Control of Your Health?

Patients interested in Chronic Care Management can contact AZZ Medical to discuss eligibility. Our team affirms Medicare or other verified coverage, explains how CCM aligns with their health needs and creates a comprehensive care plan (whether the focus is reducing medication errors, improving mobility, or preventing hospital stays).

AZZ Medical Associates delivers Principal Care Management (PCM), a focused program with similar coordination and 24/7 support for those managing a single complex condition, such as advanced cancer or post-stroke recovery.