CHRONIC CARE MANAGEMENT

Patients suffering from chronic conditions need to be cared for differently.

When a patient is dealing with a chronic condition – heart disease, dementia, hypertension, diabetes, even arthritis – by definition their condition is ever-present, which means they require a different level of care. Actual care – not just regular medication.  In recent years, the Centers for Medicare and Medicaid officially acknowledged the need for this type of care and recognized the positive impact it has on patients’ lives. They created a the program called Chronic Care Management and defined a series of activities that were required in order to effectively care for these patients in an active, on-going way. Fortunately, TapestryHealth has been delivering that level of care for years.

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Services ▸

Our Chronic Care Management program exceeds the requirements defined by CMS.  That means that our clinicians will spend at least the specific amount of time required by CMS and often quite a bit more, managing your specific condition.  We review all medications to ensure that you are getting the full benefit and make adjustments accordingly.  We carefully monitor any changes in condition and progress of treatment and are closely involved with the facility staff in creating and updating your plan of care. Everything we do is accurately documented in your medical record and is shared with any other physicians who are treating you.  But what really sets TapestryHealth apart is that you will always be dealing with the same clinicians -- care givers who will get to know you and will make adjustments to your care plan based on your physical, cognitive, psychosocial and functional conditions.  We’re not just doctors – we’re your doctors.

Enrollment ▸

Residents of skilled nursing facilities can take advantage of our CCM program even if they don’t use TapestryHealth as their primary care physician, and they don’t need to change any existing physician relationships they may have.  All that’s needed is to let the nursing staff know that you would like to take advantage of TapestryHealth’s Chronic Care Management program.  That’s it!  There are no costs to the patient because this is an approved – and highly encouraged – service by the Centers for Medicare and Medicaid. 

FAQ ▸