Chronic Care Coordination (CCC) is a care management service at St. Anthony that provides continuous support for patients with two or more chronic conditions. A physician and qualified care team spend time managing the patient’s condition. This includes a comprehensive plan of care, medication management, education, the establishment of planned end-of-life care and coordination of care between care providers. CCC provides a team-based, integrated approach to health management and addresses many factors that affect health outcomes.
Barb Toohey, RN and Amy Wiskus, RN spearheaded the development of the program along with physicians, Lindsey Pogge, D.O. and Jillianne Murray, D.O.
"This new service will follow and support patients, as needed, to ensure they remain appropriately engaged in their care and adhere to their recommended care,” said Barb Toohey.
“This service is a long time coming, we feel this will assist our patients in working toward their health and quality life goals but also impact our clinic quality outcomes as well as assist with positive value-based reimbursement,” stated Eric Hammer, V.P. of Regional Operations.
For the first three months, Amy and Barb will work with referrals from Dr. Pogge and Dr. Murray. Beginning January 1, 2023, all clinic providers will be educated about CCC, and we expect to build a strong viable service for our patients.
If you have Medicare or both Medicare and Medicaid and have two or more chronic conditions, Medicare is offering CCC services to assist a patient in managing their health. The chronic conditions include Alzheimer’s disease and related dementia, arthritis, asthma, atrial fibrillation, autism spectrum disorders, cancer, cardiovascular disease, congestive heart failure, chronic obstructive pulmonary disease, depression, diabetes, hypertension, substance use disorder, or an infectious disease such as HIV/AIDS.
Patients must consent to the CCC service and Medicare Part B or insurance is billed, but most patients should not expect to pay any out-of-pocket for the service. Patient information sheets as well as CMS Care Management information cards are distributed throughout the clinics, SHIP office, and hospital 3rd floor pamphlet rack. Ask your provider or nurse about the CCC program or contact Barb Toohey at ext. 5952, Amy Wiskus ext. 5954 or the clinic at 712-792-2222.