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Chronic Care Management

Chronic conditions such as congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, diabetes, asthma and arthritis are difficult enough on their own, but even more challenging if you are dealing with more than one chronic condition at the same time.

CMG's Chronic Care Program is here to assist you in managing these types of conditions with a long-term plan so you can be as healthy as possible. This additionsl resource allows us to reach beyond what your primary care physician can provide alone and is now part of your Medicare benefits.

Carson Medical Group's Chronic Care Program is led by your Primary Care Physician and includes specialized Nurse Practicioners, Patient Navigators/Advocates, and health educators. Your personal care team works with you to create a working action plan that assists you in meeting and maintaining your goals.

Reaching Your Goals
Carson Medical Group's care team is dedicated to working with you to proactively manage your condition by teaching you to watch for symptons and give you strategiesfor dealing with your unique health challenges. Our educational tools give you control over reaching your goals and to help you quickly get the treatment and support you need.

Carson Medical Group's Chronic Care Program is instrumental in:

  • Creating an individualized action plan to address specific treatment in-line with your choices and values
  • Assistance creating health goals and addressing barriers to meeting these goals
  • Staying on track with weekly or monthly reminders to encourage you to keep with your action plan and to address questions you have regarding your conditions
  • Coordinating the resources for your plan at home and within the community
  • Scheduling preventative screenings, medication reconciliation and appointments with your primary care physician or care team member
  • Assisting with managing your medications
  • Access to your provider, or care team, 24 hours a day, 7 days a week, for urgent chronic care needs, through telephone or CMG's Patient Portal
  • Management of your care between all health care providers and settings such as:
    • Referrals to other health care providers
    • Follow-up after an emergency department visit
    • Follow-up after being discharged from the hospital or other facility (e.g. skilled nursing