Chronic Care Management in Hudson and Trinity, FL

Chronic Care Management is a Medicare program that adds support between office visits for people living with two or more chronic conditions expected to last at least 12 months. Our Hudson and Trinity offices offer this program to help you keep your care plan organized, your medications current, and your other providers connected. The goal is steady progress on your health between appointments, with one team that knows your history.

What Chronic Care Management includes

The program centers on a written care plan that you and your provider build together. The care team then helps you follow that plan between visits. Chronic Care Management may include:

• A comprehensive care plan that lists your conditions, goals, medications, and next steps
• Regular review of your medications to keep them current and working well together
• Care coordination with specialists, labs, pharmacies, and other providers
• Help with transitions, such as follow up after a hospital stay or a stay at a skilled nursing facility
• Coordination with home health and community services when needed
• Communication with the care team through the patient portal

Common conditions that may qualify include diabetes, high blood pressure, heart disease, COPD or asthma, kidney disease, high cholesterol, thyroid conditions, and osteoporosis. Your provider decides with you whether the program is a good fit.

What to expect when you enroll

Enrollment starts with a conversation during an office visit. Your provider explains how the program works, what it includes, and how billing works. The program requires your consent, and you can ask questions before you decide.

Once you agree, the next steps usually look like this:

1. Your provider reviews your conditions, medications, and goals with you
2. The team creates your written care plan and shares a copy with you
3. The care team follows your plan between visits, checking on medications, results, and referrals
4. Your plan is updated as your health and goals change

Your regular office visits continue as scheduled. Chronic Care Management adds support around those visits, so questions and changes can be handled in an organized way. Because our providers share one chart across both offices, your plan stays consistent wherever you are seen.

Who this care is for

Chronic Care Management is for people with Medicare who have two or more chronic conditions expected to last at least 12 months. It is especially helpful if you:

• Take several medications and want them reviewed together
• See more than one specialist and want your care connected
• Have recently been in the hospital or a care facility
• Want a clear written plan for managing your health
• Have family members or caregivers who help coordinate your care

If you are not sure whether you qualify, ask at your next visit or during your Medicare Annual Wellness Visit. You can also learn more about our broader chronic disease management approach.

Insurance and coverage

Chronic Care Management is a Medicare covered service. The usual Part B coinsurance and deductible may apply. Medicare Advantage plans may have their own rules. Please call the office to verify your coverage before enrolling.

Call 911 for emergencies such as chest pain, trouble breathing, or stroke symptoms. Chronic Care Management supports your ongoing care and is not meant for emergencies.

Frequently asked questions