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Improve Life with Chronic Care Management

Chronic Care Services at SICHC

by Donna Charles, Chronic Care Nurse Manager with Southern Indiana Community Health Care • 

Are you personally facing or know someone who is dealing with healthcare issues involving two or more chronic conditions? As people age (or face other health-related issues), receiving high-quality care for multiple issues can become a challenge.  To reduce these challenges and help improve quality of life, Southern Indiana Community Health Care offers CMS-supported chronic care management services.

Patients on Medicare with two or more chronic medical conditions (e.g. Alzheimer’s arthritis, hypertension, cancer, COPD, diabetes, depression, or other conditions) can qualify for Chronic Care Management from Community Health Care. “We take them under our wing to help them achieve the highest quality of life possible,” says, Donna Charles, a Chronic Care Nurse Manager with Southern Indiana Community Health Care.

“When we work with people in the Chronic Care Management program, we generally get to know them very well,” Charles said. “Patients have 24/7 access to our providers through a chronic care nurse or one of our on-called nurses.

An assigned nurse will work with the patient and provider to put together a comprehensive care plan. The plan will list the conditions, symptoms, and problems that the patient is facing, together with treatment goals, expected outcomes and prognosis, medication management, and more.

Nurses in the program go beyond just seeing patients. Where applicable and practical, nurses and professionals address transportation and housing issues, as well as assisting with personal care needs like managing prescriptions and refills and creating “med packs” to help patients be able to actually take their medications. “It can be difficult for someone with arthritis to open a pill bottle, so we take care of that,” said Charles.

Chronic care management under CMS is designed so there are no financial issues for services with patients. “We also manage care transitions both between and among healthcare providers,” Charles explained. “These transitions can include securing referrals to other professionals and clinicians, or needed follow-up care after a patient visits an emergency department or is discharged from a hospital.” 

Interested in seeing whether you qualify for Chronic Care Services? Talk with a provider. If qualified, the provider can make a referral and get you set up.

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