Chronic Care Management

The Abbeville Area Physician Network is committed to helping our patients start their journey to wellness, no matter what their age. Our Chronic Care Management (CCM) Program helps those in their “Golden Years” who are experiencing multiple chronic health conditions create a plan that considers all aspects of their health and achieve a better quality of life!

The CCM Program care team creates individualized plans for patients that include care coordination information, health goals and challenges, healthcare providers, medications and community services and resources. 

Program participants receive monthly calls or home visits from a Chronic Care Nurse who is available to assist patients with all aspects of their care including:

  • Working with doctors to create a care plan that includes personalized health goals
  • Coordinating care and health records
  • Ensuring that ongoing attention is paid to medical care needs between doctor visits
  • Establishing new care with medical specialists
  • Providing community resources if needed
  • Providing reminders when preventive services and immunizations are needed
  • Helping patients to understand medications and medical conditions
  • Ensuring doctors and family members have easy access to your care plan

What are considered chronic conditions?

Diabetes
Hypertension
Chronic Obstructive Pulmonary Disease (COPD)
Congestive Heart Failure (CHF)
Obesity
Cancer

Alzheimer’s/Dementia
Depression
Asthma
Stroke
Kidney disease

Who is eligible to receive CCM and how do I enroll?

To enroll, you must:

  • Be an active patient of the Healthcare Center, Due West Family Medicine or Savannah Lakes Family Medicine.
  • Have two or more chronic conditions
  • Give an initial verbal consent to participate
  • Sign a written consent within one year of starting services after speaking with your doctor regarding your eligibility

How much does CCM cost? Is it covered by insurance?

Most of the CCM Program is covered by Medicare once the deductible is met. Depending on the plan, the patient may be responsible for a small portion of the cost.  Supplemental coverage may reduce the portion owed or pay it in full.

To make an appointment, call us at (864) 379-2345.