Chronic care management

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Our team will diagnose and help manage your conditions to ensure you get the best care possible.

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Care Management for Chronic Conditions

The care team at Avance Care is prepared to help patients with all types of chronic disease. A chronic condition requires ongoing treatment and monitoring; in other words, there is no cure. Many patients with chronic illnesses have multiple conditions. Our approach to chronic care management rests on a healthy patient-doctor relationship.

Our medical providers who treat chronic disease strive to educate patients and provide ways for patients to self-manage their disease. Many aspects of self-care are emphasized, such as nutrition, emotional health, sleep quality, and overall well-being. Our providers are committed to spending sufficient time with each patient to address health concerns in depth and provide the best possible care.

Common Chronic Diseases

Alzheimer’s disease
Arthritis
Asthma
Chronic obstructive pulmonary disease (COPD)
Coronary artery disease
Depression
Heart disease
Type 1 diabetes
Type 2 diabetes
Rheumatoid arthritis
Multiple sclerosis
Parkinson’s disease

Chronic disease management works best when a patient and doctor can work together with the support of a chronic care management team. At Avance Care eligible patients with a chronic condition are connected with a care manager who is an important part of your care team, helping improve patient outcomes and reduce the instances of unnecessary or expensive medical services. Having a care manager to contact who understands the complex healthcare system and your unique condition can make all the difference. This could be the difference between a weekend at home with your family or hours (or even days) at the hospital.

Chronic Care Management (CCM) FAQs

Care Management is a set of activities intended to improve patient outcomes and reduce the instances of unnecessary or expensive medical services by helping patients more effectively manage their health conditions.
Avance Care patients with Medicare or Medicare Advantage with two or more chronic conditions are eligible for care management services. Example of conditions include diabetes, hypertension, cancer, COPD, cardiac conditions (CHF, cardiomypopathy, CAD), asthma, arthritis, renal failure.
- Ongoing chart review to identify issues that should be discussed and addressed
- Coordination of care between specialists, testing centers, and hospitals
- Assistance in making follow-up appointments and appointments with specialists
- Monthly check-ins and personalized attention for you and your health management goals
Avance Care’s Chronic Condition Management service is designed to meet Centers of Medicare and Medicaid Services Chronic Care Management (CCM) program.
It includes a minimum of 20-minutes of non-face-to-face time per month with patients in coordinating care and additional support for your overall health.
Healthcare is complicated and we are here to help you navigate the system – from billing questions to insurance issues and referrals, our care team is here to help guide you through your healthcare journey.
Our Care Coordination team works in collaboration with your Avance Care primary care provider to connect you to the most appropriate high-value specialists and partners to ensure you get the best care possible.
A High Value Specialist (HVS) is a well-accomplished medical provider in their field that schedules appointments in a timely manner and stays in close communication with your primary care provider. These HVS are not selected based on a financial agreement—only their ability to provide seamless, collaborative, high quality and cost-effective care.
In the event a trip to an urgent care, emergency room, or hospital visits cannot be avoided, our CCM provides the support you need during the critical transitional care period after a hospital discharge to ensure a quick recovery and a reduced possibility of readmission.
If Avance Care is identified as your primary care provider when you are admitted, we will receive automatic notifications regarding your care. Included in these notifications are the reason for your visit, tests that were performed, findings that were assessed, as well as the attending physician’s recommended plan of care.
The Transitional Case Management (TCM) program supports members in transition from an inpatient setting to a home setting. In an effort to prevent avoidable readmissions, TCM consists of discharge follow-up and case management.
The TCM team works closely with members and their physicians to support and reinforce treatment plans, emphasizing symptom management and patient empowerment. TCM team may include Registered Nurse, Dietitian, Behavioral Therapists, and others as needed.
Members are often automatically enrolled in the CCM program upon hospitalization.
Discharge follow-up calls are made to assist the member with:
- Treatment plan adherence
- Medication adherence
- Physician follow-up
- Disease process education
- Caregiver availability information
- Homecare evaluation and resources
- Referrals to other case management/disease management programs
At the core of these programs is health education as well as a focus on self-care and close follow-up with the treating physician. Participants have access to information and resources that focus on education, prevention and health reminders.

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