Chronic/Complex Care Management (CCM)
CCM at Avenue
Avenue’s Chronic/Complex Care Management (CCM) is a program designed for patients with two or more chronic conditions expected to last 12 months or more or place them at significant risk of death, acute exacerbation/decompensation, or functional decline.
The most common chronic conditions we support are: HTN, Diabetes, CHF, Hyperlipidemia, COPD, Obesity, Depression, Cancer, Osteoarthritis and Dementia. We can design programs for other CCM conditions to meet the needs of your practice.
Avenue’s CCM services provide
- Comprehensive assessments and person-
centered care plans - Patient education (disease process, medication, community resources)
- Preventive service reminders
- Transition of care management
- RN continuity for optimal patient and caregiver engagement and experience
- Care coordination and information exchange with Specialists and other providers
- Support using motivational interviewing techniques to affect lasting health behavior change
- Transition of care management
- 24/7 patient access to care and health information
- Provide patients and or caregivers with copy of the care plan
- Comprehensive billing reports for practice
- Patient advocacy
Other Avenue Health Coach Activities / Coordination / Referrals:
- Prescription Assistance, Medication Assistance Programs and Co-Pay Assistance Programs
- Transportation coordination
- Preventive service reminders
- Advance Care Planning
- Community/SDOH resources -good insecurity, utility assistance, housing assistance
- PHQ9 Assessments
- Dietician, specialists, nutritional Programs
- Transition of care management
- Medicaid Assistance/Social Worker
- Senior well-being and senior day program
While CCM services are covered by many insurance plans, some plans may require a small co-insurance.
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