Chronic care management is a physician-led, patient-centered care team encouraging active patient participation with follow-up support to provide the right care at the right time.
Our goal is to transform medical care in three directions.
The Triple Aim is to:
- Improve the health of our patient population.
- Enhance the patient experience of care including quality, access and reliability.
- Reduce, or at least control, the cost of health care.
Your Chronic care management team is a group of health care professionals who plan and deliver patient care in a coordinated way with the patient. The care team includes at least one primary care provider, a registered nurse, a care coordinator and may include other health professionals based on the patient’s needs.
Care coordination helps ensure a patient’s needs and preferences for care are understood, and are shared between providers, patients and families as a patient moves from one healthcare setting to another.
As a team we will develop a written plan to guide your care called a Care Plan or Action Plan.
Chronic Care Management Team
Patient
You are the most important member of the care team. A care plan will be developed as a result of shared decision-making according to your specific health goals.
Physician, Physician Assistant or Nurse Practitioner
Your physician, physician assistant or nurse practitioner remains in charge of your care and is assisted by your care coordinator and other members of your care team to develop and coordinate your care plan.
Chronic Care Management Registered Nurse
The Chronic Care Management RN consults with you and your provider and assists you with your medical concerns. Our primary goal is to reduce hospital admissions and facilitate transition back to primary care at discharge, educating on chronic health concerns/medications, and assessing patient needs as they arise. Chronic Care Management RNs are available Monday—Friday during clinic hours.
Care Coordinator
Your Care Coordinator helps coordinate your care by consulting with your Provider and Chronic Care Management RN. The Care Coordinator can assist you with medical concerns, social and community resources, and will contact you as often as needed.
Additional Team Members
Clinical Assistant
A clinical assistant provides direct patient care such as labs, immunization and x-rays under the supervision of the provider.
Referral Coordinator
The referral coordinator will work with you to schedule referral appointments.
Triage Nurses
Entira Family Clinics has a telephone triage department, staffed with specially trained registered nurses who are ready to take your call from 7 a.m. to 5 p.m., Monday through Friday. The nurses will listen to your concerns and offer advice or recommendations for appropriate, timely medical care. Entira registered nurses work in close contact with providers to ensure you receive the best medical care available.
Patient Responsibilities
As you communicate with your care team, it is important for you to be an active partner in your health care:
- Bring a list of questions to your appointments and tell your care team when there is something you don’t understand.
- Keep your care team informed of changes in your needs or health care received from other professionals.
- Bring all of your medications to each visit and share any problems or questions regarding medications with your care team.
This is the time for patients to become more involved in their health care to help us provide needed services. Contacting Your Care Team
Your care team is available for you 24/7/365. You can reach us by phone for all questions or to make an appointment if needed.
To reach your Chronic Care Management team, call your primary care clinic phone number.
Phone Call Hours and Information
From 7:00 a.m. to 6:00 p.m. your calls will be answered by our scheduling staff and routed based on your needs.
- Please let us know which member of your Chronic Care Management team you wish to speak with.
- If your team member is unavailable, a telephone message will be taken, or you will be placed in their voicemail. Calls will be returned within 24 hours.
From 5:00 p.m. to 9:00 p.m. your call will be answered by our After Hours Care staff or our On Call answering service, depending on your needs.
From 9:00 p.m. to 7:00 a.m. your call will be answered by our On Call answering service and routed to an On Call physician.
