Geriatric Medicine

Since 2015, the Centers for Medicare and Medicaid Services of the United States Department of Health and Human Services have recognized Chronic Care Management as a critical component of primary care that contributes to better health and care for individuals.  Chronic Care Management (CCM) .  CCM is available to any patient covered under Medicare who has two or more chronic medical conditions which are expected to lat at least 12 months and place the patient under significant risk of death, acute exacerbation/decompensation, or functional decline.  A comprehensive plan of care will be established, implemented, revised and monitored by the treating physician.  SUch medical conditions in Alzheimer’s dememtia, arthritis (osteoarthritis or rheumatoid), asthma, atrial fibrillation, autism, cancers, cardiovascular disease, COPD, depression, diabetes, hypertension and/or infectious diseases such as HIV/AIDS.  This program is only available from Primary Care Physicians who are currently treating the patient.  The DiGiovanna Family Health and Wellness Center has implemented a Chronic Care Management program which is available to appropriate patients.  This program will allow for the development of a Comprehensive Care Plan for the participating patient.  The Comprehensive Care Plan will allow participating patients 24-hour-per-day, 7-day-per-week (24/7) access to the DiGiovanna Family Health and Wellness Center providers or clinical staff, including a means to make contact with our providers to address urgent needs, ensure continuity of care with a designated member of our health care team who is able to schedule subsequent appointments, and provide enhanced opportunities for the patient and any caregivers to communicate with the practitioner regarding our patient’s care by telephone and/or secure messaging and/or secure email.  The Comprehensice Care Plan will also include Comprehensive Care Management to assess and address our patient’s medical, functional and psychosocial needs, system-based approaches to ensure timely receipt of all recommended preventive care services, medication reconciliation with review of adherence and potential interaction. oversight ofpatient self-management of medications and coordinating care with home and community cased clinical service providers, and last to provide Transitional Care Management to manage the transitions between and among health care providers and settings, including referring to other clinicians, and follow-up care after an emergency department visit or facility discharge.