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For Patients

For Patients

Care Management Program

The Chronic Care Management Program, which is primarily done by phone conversations with your Care Manager, is designed to improve the coordination of your healthcare with an emphasis on your overall well-being. We believe to achieve this goal there must be a partnership between the patient, their family, their healthcare provider and staff and their Care Manager. By remaining involved in the decisions regarding your health, healthcare and lifestyle, we can develop a stronger relationship with you.

The Care Management Program will help your reach your health goals by:

  • Identifying missed preventive care opportunities and work with you to schedule these services during a time that is convenient for you
  • Working closely with your Primary Care Provider (PCP), to set your health goals
  • Working with you and your PCP to establish a plan of care that works for you
  • Providing ongoing monitoring and coordination with your PCP as your medical needs change
  • Serving as a resource to you and your family, answering questions about your health or any healthcare needs
  • Contacting you after your hospitalization to ensure you are receiving the care you need and have a follow up appointment with your PCP or specialist
  • Providing you with a dedicated Care manager to serve as your one source point of contact
  • Providing you with a personalized healthcare plan to help you meet your goals


What are the benefits of program participation?

We strive to make understanding your healthcare as easy as possible. Some benefits of Chronic Care Management include:

  • Education on a healthy lifestyle
  • Education on the benefit of preventive health service
  • Providing you with reminders about health services that are due
  • Information regarding your specific health conditions and set goals
  • Identification of additional health problems
  • Ongoing support to meet changing care needs
  • Collaboration with your PCP and specialist about any services to meet your healthcare needs
  • An individual and personalized care plan specific to you and your healthcare needs
  • Consistent and ongoing collaboration with your dedicated Care Manager to meet your healthcare needs.

Is program participation required?

You are not required to participate in the Care Management Program; however, your PCP highly encourages you to do so. Chronic Care Management Programs are provided to improve health outcomes and help you meet your health goals.

Is there a cost to participate?

We will bill Medicare for these services any month we have provided at least 20 minutes of non-face to face care of you and your conditions. You may or may not have a co-pay or co-insurance depending on your Medicare benefits plan.

What can I expect from my participation?

Chronic Care Management is first and foremost a partnership with you; you will actively participate in your health improvement plan. We will provide accurate and useful information tailored to your medical situation and advice from your provider. Your dedicated Care Manager will reach out to you at least once a month, sometimes more frequently, to check in and see how you are doing. Your Care Manager will also review your personalized Care Plan and how you are doing towards your goals. Your PCP will discuss your health needs, and set and monitor your healthcare goals specific to you.

What should I do in an emergency medical situation?

Chronic Care Management works to coordinate all of your care, but a medical emergency can happen at any moment. If your medical need is urgent, please visit one of our Urgent Care clinics – located at our West Des Moines, Ankeny and South Waukee Campuses. In the event of an emergency, please call 911.

Who are Care Managers?

The Care Managers are healthcare professionals trained specifically to provide health coaching and education to patients. You will have a Care Manager that works exclusively with you, your PCP and your support system. Care Managers are Registered Nurses (RNs) or Certified Medical Assistants (CMAs). Your Care Manager will provide you with their contact information.

How did I get chosen for this program?

Patients with various medical conditions are referred to the Chronic Care Management Program by their PCP. Your PCP has identified you for the Chronic Care Management Program because they feel you would benefit from additional support and education for your healthcare. The Care Manager will work closely with your PCP and specialist to help you meet your health goals.

What about the confidentiality and security of personal health information?

Your Chronic Care Manager is part of your healthcare provider’s team and complies with HIPAA as well as all State and Federal confidentiality laws. Our patients’ confidentiality is very important to our team.

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