Chronic Care
Personalized Support for Patients with Chronic Conditions
Chronic Care Management (CCM) at Oak Medical
Chronic Care Management (CCM) is designed to improve care coordination for patients with two or more chronic conditions. Our RN program offers structured, ongoing support to ensure patients receive the comprehensive care they need between visits, reducing hospital readmissions and enhancing their quality of life.
What is Chronic Care Management?
Access to 24/7 Clinical Support Team
In-between visit management of chronic conditions
Continuous monitoring of medication adherence
Ongoing assessment of symptom changes
Individualized support for better patient engagement
Assure patients remain stable and well supported in-between visits
Tailored strategies to meet individual patient needs
Examples of Conditions that CCM Supports
Diabetes
Hypertension
Heart Failure
Alzheimer’s or Dementia
COPD & Chronic Respiratory Diseases
Arthritis & Chronic Pain Conditions
Chronic Kidney Disease
Benefits
Overall improvement in patient’s quality of life
Improved access to care team
Increased patient satisfaction
Reduced ER visits and hospitalizations
Care coordination with specialists and families
Patient-Centric Model
Our systems are designed to keep the patient experience at the center while streamlining operations for facilities. Offering a single touchpoint for patients, their families, and facility staff saves time, enhances communication, and positively impacts care by removing obstacles.