CHRONIC CARE MANAGEMENT (CCM)
Coordinated Care for
Your Whole Health
Ongoing Support for Managing Multiple Chronic Conditions
Managing rheumatoid arthritis alongside high blood pressure, or lupus alongside diabetes, can make care complicated fast. Different providers. Different medications. Labs that need follow-up. Instructions that do not always align.
Chronic Care Management helps bring it all together. Our care managers work under the direction of Dr. Ayesha Kanwal to coordinate your care, keep your treatment plan on track, and stay connected with you between office visits. With monthly check-ins and ongoing monitoring, we can identify problems earlier and help keep everyone involved in your care on the same page.
Chronic Care Management (CCM) is a Medicare-supported care coordination program for patients living with two or more chronic conditions that are expected to last at least twelve months, or for the rest of their lives, and that place them at risk of decline, hospitalization or worsening function.
Instead of care happening only when you are in the exam room, CCM adds structured support in the weeks between. You get a comprehensive care plan, a care team you can reach, and at least one scheduled contact each month with someone who knows your history and can act on what you tell them.
You may be eligible if you are living with two or more ongoing conditions. For our patients, that most often looks like a rheumatologic condition paired with another chronic diagnosis.
If two or more of these describe you, ask us. Eligibility is straightforward to check, and we can confirm it in a single phone call.
Your care management team here is not a call center. It sits inside a rheumatology practice, works under Dr. Ayesha Kanwal, and reads the same chart your physician does. When your care manager escalates something, it goes to the specialist who already knows your case.
That matters for autoimmune and inflammatory disease, where a change in symptoms can mean a flare, a medication problem, or something unrelated entirely and where the difference between those three is a clinical judgment, not a checklist.
Chronic Care Management is covered by Medicare Part B and by many other insurance plans. Depending on your coverage, standard deductibles and coinsurance may apply, and some patients have no out-of-pocket cost at all.
We will verify your benefits and tell you exactly what to expect before you enroll. You will never be signed up for this program without knowing what it costs.
No. CCM is delivered between your appointments, mainly through a scheduled monthly phone call. It does not add office visits to your schedule.
CCM is for patients with two or more chronic conditions and coordinates care across all of them. PCM is for patients with one serious condition that requires specialist management. If your rheumatologic condition is your only chronic diagnosis, PCM is likely the better fit. If you are managing it alongside diabetes, high blood pressure or another ongoing condition, CCM covers everything together.
Yes. The two work well together. CCM provides the care plan and the monthly coordination, and RPM adds home readings your care team reviews in between. We will confirm your coverage for both before enrolling you.
A care manager on our rheumatology team, working under Dr. Ayesha Kanwal and with access to your chart. You work with the same care manager over time, so you are not starting from the beginning on every call.
Enrolment is voluntary and you can withdraw at any time. Tell your care manager or call the office. There is no penalty and it does not affect your regular care with Dr. Kanwal.
No. CCM works alongside your primary care provider rather than replacing them. Part of what your care manager does is communicate with your PCP and your other specialists so that everyone treating you is working from the same information.