Healthcare That’s All About You
A healthcare team that understands what you need at every stage. Conveniently designed to accommodate your everyday health needs.
Dr. Ravinder Singh
Discover the Benefits of Medicare's Chronic Care Management (CCM) Program
If you live with two or more chronic conditions like diabetes, high blood pressure, arthritis, or heart disease, you may qualify for a special Medicare program that offers extra support between your regular doctor visits.
This program is called Chronic Care Management (CCM)– and it’s designed to make life easier for seniors managing long-term health issues.
No more waiting weeks or months for an appointment time.
Work with providers who give more than just a prescription.
Stop feeling rushed during your time with the doctor.
Feel like a person, not just a patient file.
What is Chronic Care Management?
CCM gives you monthly support from your care team, helping you stay on top of your health without needing extra office visits. You’ll have a dedicated care coordinator who checks in regularly, helps manage your medications, arranges follow-ups, and is available to answer questions anytime-even after hours.
What's Included:
✅ A personal care plan tailored to your needs
✅ Monthly check-ins by phone
✅ Help managing your medications and appointments
✅ Coordination between all of your doctors and specialists
✅ 24/7 access to a care team for urgent needs
✅ Support after hospital stays or ER visits
What's the cost?
This program is covered by Medicare, and many patients have supplemental insurance (like Medigap) to cover any copay. Ask your provider if this applies to you.
We also have hardship waivers for those who may not be able to cover the cost.
Common Chronic Diagnosis
This list is not exhaustive but reflects the most common conditions qualifying patients for chronic care services.
Cardiovascular
- Hypertension (I10)
- Coronary Artery Disease (I25.10)
- Congestive Heart Failure (I50.9)
- Atrial Fibrillation (I48.91)
- Hyperlipidemia (E78.5)
- Peripheral Artery Disease (I73.9)
Endocrine
- Type 2 Diabetes Mellitus (E11.9)
- Hypothyroidism (E03.9)
- Obesity (E66.9)
- Metabolic Syndrome (E88.81)
Respiratory
- Chronic Obstructive Pulmonary Disease (COPD) (J44.9)
- Asthma (J45.909)
- Sleep Apnea (G47.33)
Musculoskeletal
- Osteoarthritis (M19.90)
- Rheumatoid Arthritis (M06.9)
- Osteoporosis (M81.0)
- Chronic Back Pain (M54.5)
Neurological
- Alzheimer’s Disease (G30.9)
- Dementia (F03.90)
- Parkinson’s Disease (G20)
- Epilepsy (G40.909)
- Migraines (G43.909)
Behavioral Health
- Depression (F33.9)
- Generalized Anxiety Disorder (F41.1)
- Bipolar Disorder (F31.9)
- PTSD (F43.10)
- Schizophrenia (F20.9)
Gastrointestinal / Liver
- GERD (K21.9)
- Irritable Bowel Syndrome (K58.9)
- Inflammatory Bowel Disease (Crohn’s/K50.90, Ulcerative Colitis/K51.90)
- Chronic Liver Disease/Cirrhosis (K74.60)
Renal / Urologic
- Chronic Kidney Disease (N18.9)
- Urinary Incontinence (R32)
- Benign Prostatic Hyperplasia (N40.0)
Hematologic / Oncologic
- Anemia (D64.9)
- Sickle Cell Disease (D57.1)
- Cancer (varies by type; e.g., C50.919 for breast cancer)
Infectious Diseases
- HIV/AIDS (B20)
- Chronic Hepatitis B/C (B18.1 / B18.2)
Other Chronic Conditions
- Chronic Pain Syndrome (G89.4)
- Fibromyalgia (M79.7)
- Lupus (M32.9)
In Office
In-Office Visits
From chronic conditions to routine well visits, we’re committed to our patients for the long term. We get to know you and your health as a whole.
Online
Virtual Visits
Quick and convenient, choose a visit when you have a non-urgent medical need or when your schedule or a current health condition make in-person visits difficult.
Specialty
Senior First Program
We realize older patients have unique healthcare needs. Understanding these special circumstances is why we created a Seniors First Program.
How to Join the Program
You can join the CCM program by talking to your PCP, Completing the form below, or by calling or call us at 909-285-4558