Care Management & Coordination

Chronic care management, transitional care, and family engagement for better outcomes.

Learn About CCM Care management team

Program Overview

  • Chronic Care Management (CCM)
  • Transitional Care Management
  • Annual Wellness Visits
  • Behavioral Health Integration

Care Team Structure

  • Dedicated care coordinators
  • Clinical protocols
  • Family engagement model
  • PCP collaboration

Technology Platform

  • Care plan development
  • Progress tracking
  • Outcome measurement
  • Reporting capabilities

Success Metrics

  • Hospital readmission rates
  • Medication adherence
  • Patient satisfaction
  • Quality measures