Chronic Care Management Program

Our program connects patients with a dedicated personal care contact who supports them between appointments with medication refills, referrals, and any health concerns that arise. Patients have direct phone access for immediate help and receive monthly check-in calls to ensure they stay on track with their care.

What is Chronic Care Management (CCM)?

Our Chronic Care Management (CCM) program is designed to provide continuous, personalized support for patients. If you are living with two or more chronic conditions, such as diabetes, high blood pressure, COPD, asthma, anxiety, or depression, CCM is covered by Medicare, often with little to no cost to you. Beyond your regular office visits, this program offers a dedicated personal contact who serves as your direct link to better health. Your coordinator assists with medication refills, specialist referrals, and any health concerns that arise, ensuring you never have to navigate your wellness journey alone. By providing consistent oversight and monthly check-ins, we help you manage your conditions more effectively and reduce the need for unnecessary hospital visits.

Once enrolled, you will receive a direct phone number for immediate assistance between appointments, and our team will reach out to you once a month to monitor your progress and address any needs. Our goal is to simplify your healthcare experience by providing the reliable, ongoing attention required to maintain your quality of life and keep your care plan on track.

Meet Our Chronic Care Management Team

Karen

Catherine

Bailey

Rebecca

How Our Team Supports You

Your Own Personal Care Coordinator
Medication Support

Appointment Assistance
Ongoing Health Monitoring

Fewer ER Visits & Hospital Stays

What is included in CCM?

You get personal help managing your conditions

With CCM, a dedicated care coordinator checks in with you every month to help track your symptoms, monitor your progress, and make sure you are staying on the right path. This gives you ongoing support between doctor visits.

Stay on track with medications and appointments

Your care team helps you keep up with medications, refills, and doctor appointments so nothing slips through the cracks. They can help schedule follow-ups and send reminders.

Reduce your risk of hospital visits

When you stay on top of your care and catch problems early, you are less likely to end up in the emergency room or hospital. CCM helps detect changes in your health before they become serious.

You are always connected to a helathcare team

If you have a concern or new symptom, your CCM team is there for urgent questions or concerns. You’re never alone in managing your health.

Covered my medicare

If you have Medicare, CCM is often covered with little to no cost to you.

Serving Tulsa’s Community For 14 Years!