Program Helps Seniors Manage Chronic Conditions

Horizon Health offers Chronic Care Management by Medicare

Horizon Health now offers Chronic Care Management (CCM), a Medicare program that helps participants understand and live successfully with their long-term medical conditions.

Under this optional program, patients are actively involved in managing their chronic illnesses. The intent is to reduce unnecessary emergency room visits, readmissions to the hospital, and costs of duplicate testing.

CCM is not an emergency service, but gives patients access to qualified nurses who can assist them with a comprehensive care plan that has been designed especially for them. CCM services are performed independently of a regular office visit.

“The goal of CCM is to educate and empower patients to make better choices because they understand their medical conditions,” said Rhonda Walker, RN, care coordinator at Horizon Health. “This puts them in control and gives them the tools to help understand and manage their health.”

The CCM program offers the following benefits:

• Each patient can expect a minimum of 20 minutes of personalized care with a Chronic Care Management team member.
• A dedicated phone line is available for patients to talk to a CCM nurse. If a nurse is not available at the time of the call, a nurse will return the call within one hour.
• In addition to the dedicated phone line, a Chronic Care Management nurse calls patients every month to check-in and addresses any health-related concerns the patient may have.

“We want to catch problems early to avoid conditions from worsening, answer questions, give reminders of follow-up appointments, and ensure patients are taking their medications as prescribed. The nurse can also provide additional resources,” Rhonda said.

Patients can enroll in the service following a discussion with their primary care provider or a CCM nurse. To qualify for the program, patients must meet the following requirements as defined by Medicare:

• Have two or more chronic conditions expected to last at least 12 months. Some examples can include cardiovascular diseases, diabetes, cancer, hypertension, asthma, Alzheimer’s disease and related dementia.
• Have had a face-to-face encounter with their primary care provider within the past 12 months.
• Provide signed consent to enroll in the program. There is a small cost. Medicare patients can expect to pay $12 dollars a month. If they have secondary insurance, the cost may be covered. Patients can terminate the service at any time. There is no contract.

Medicare Wellness Visits

Individuals can sign up for the Chronic Care Management program at the same time a free Medicare Wellness Visit is being done. The Wellness Visit is available annually and at the patient’s first introductory meeting to Medicare. The Wellness Visit creates an individualized preventive care plan based on a person’s health and risk factors. It is not an actual head-to-toe physical exam, and does not replace a person’s annual physical exam.

For more information about the Chronic Care Management and free Medicare Wellness Visits, call Rhonda Walker at (217) 466-4748.