Chronic Care Management

Esteem’s Chronic Care Management program is a patient-centered care plan based on a physical, mental, cognitive, psychosocial, functional, and environmental (re)assessment, and an inventory of resources (a comprehensive plan of care for all health issues).

The Centers for Medicare & Medicaid Services (CMS) recognizes care management as one of the critical components of primary care that contributes to better health and care for individuals, as well as reduced spending.

Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline are eligible for the CCM service.

Examples of chronic conditions include, but are not limited to, the following: `

  • Alzheimer’s disease and related dementia;
  • Arthritis (osteoarthritis and rheumatoid);
  • Asthma;
  • Atrial fibrillation;
  • Autism spectrum disorders;
  • Cancer; `
  • Chronic Obstructive Pulmonary Disease;
  • Depression;
  • Diabetes;
  • Heart failure;
  • Hypertension;
  • Ischemic heart disease;
  • and  Osteoporosis.