Staying Healthy with Chronic Care Management

By Mary Kelly-Pelletier, RN, BSN, Director of Nursing, Oak Orchard Health 

Living with a long-term health condition like diabetes, heart disease, or high blood pressure can be difficult. That’s where Chronic Care Management (CCM) comes in. It’s a special program at Oak Orchard Health that helps people stay healthy and avoid hospital visits. Our CCM team works with patients one-on-one to help manage their health regularly—not just when they’re sick or when they have an appointment.

What Is Chronic Care Management?
Chronic Care Management is a program designed for individuals with two or more long-term (chronic) health conditions. These conditions can last for a year or more and often significantly impact their daily life. Common conditions include diabetes, high blood pressure, congestive heart failure, cancer, and schizophrenia. Some patients who have recently left the hospital may also qualify if they require additional support.

You do not need to be a certain age to be part of this program, though many participants are older adults. The program is designed to help you stay on track with your health and avoid future hospital visits.

Ask your OOH provider if you’re eligible. If you qualify, you’ll be connected with a care team that includes a nurse, your provider, and sometimes a community health worker.

What Does the Program Include? Education and Support

One of the most important parts of Chronic Care Management (CCM) is education. Nurses help you understand your condition, your medications, and how to care for yourself. They talk to you about healthy eating, exercise, and what symptoms to watch for. If you notice something new or feel worse, the nurse can help figure out if it’s a normal side effect or something more serious.

Regular Check-ins are Essential
Nurses will call you a couple of times each month to check in and answer any questions. It’s like having a partner in your healthcare who knows you and your health history.

Removing Barriers to Care

We know that sometimes it’s not just about medicine. Perhaps you struggle with getting to appointments, picking up prescriptions, or finding healthy food. We help with those things too. We can arrange transportation, connect you with a mail-order pharmacy, or refer you to local food programs. If cost is a problem, we’ll help you apply for discount programs, including our Sliding Fee Discount Program, which can reduce the cost of medical services based on your family size and annual income.

Keeping You Out of the Hospital

The goal of CCM is to help you stay well and avoid serious problems that lead to hospital stays. Having someone to call with questions—before things get worse—can make a big difference.

How to Get Started

If you think Chronic Care Management could help you, talk to your medical provider or call Oak Orchard Health at (585) 637-3905. Even if you don’t qualify, we’re still here to help. We believe in building a relationship with every patient, and we want you to feel comfortable asking questions.