Condition Management 2018-07-05T10:26:34-04:00
Hours of Operation: Monday – Friday:  8:00 a.m. – 5:00 p.m.   l  Contact Us: (844) 808-9347  l 

Patient Services

The Care Coordination Institute (CCI) is committed to partnering with physicians, hospitals, and other health care providers to transform the health of communities through facilitation and education around coordination of care, evidence-based best practices and the promotion of healthy lifestyles. The goal of the program is to support the practitioner/patient relationship and plan of care through risk management and establishing healthy lifestyle behaviors. Care Coordination Institute offers condition management programs for patients who are identified with diabetes, congestive heart failure, chronic obstructive pulmonary disease, asthma, hypertension and hyperlipidemia.

A patient in the program will receive educational materials and in-person meetings with a health coach. A health coach will assist patients in developing an action plan and help them understand and manage their medications. The health coach will also keep the patient’s healthcare providers informed of their action plan, goals and progress. The information a patient receives through this program does not replace their provider’s care. A patient must still discuss any questions or concerns they may have with their provider.

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Program Operations

CCI’s Care Coordination Services supports the patient-provider relationship and plan of care, while emphasizing the prevention of disease progression and complications using cost-effective, evidence-based practice guidelines and patient empowerment strategies such as self-management tools. Clinical data sources are utilized to assess and proactively identify a patient that is living with or at risk for complex and/or chronic medical conditions. All data collected through the assessment process will be stored within the patient’s electronic health record (EHR) and will be utilized to place the patient into the appropriate risk category, thereby determining the level of involvement employed by Care Coordination Services staff. Patients are selected for Care Coordination Services through diagnosis complexity, identification of barriers to improved health, compliance with treatment plan and high use of resources. Patients receive Care Coordination Services in an effort to improve overall health status, improve satisfaction and improve efficient use of resources.

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Practitioner Services

The program is designed to collaborate with practitioners and patients to identify opportunities for prevention and intervention to provide well-coordinated care. Patients enrolled in the condition management program will work with a health coach to develop a plan of care founded on evidence-based guidelines and interventions specific to their conditions or risks. Intervention plans are tailored based on screenings, immunizations, self-management education and support, medication adherence and goal-setting. The health coach will encourage adoption of healthy lifestyle behaviors and assist the patient with referrals to support groups and condition-specific programs including diabetes self- management, medical nutrition therapy, weight management, smoking cessation, and depression. The health coach will interact with patients through phone calls or in person meetings. Educational materials are given to support all self-care efforts of the patient.

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Hours of Operation: Monday – Friday:  8:00 a.m. – 5:00 p.m.   l  Contact Us: (844) 808-9347  l 
Care Coordination Institute’s Condition Management Program does not market, advertise or promote any products or services. In addition, Care Coordination Institute has no financial arrangements with other entities to advertise or market Condition Management Program products, goods or services. Condition Management protocols are developed using evidence-based guidelines which are available upon request. CCI does not represent, warrant, undertake or guarantee that the use of services or products will lead to any particular outcome or result.