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Coordinated Care for Your Chronic Conditions
HPG's CCM program gives you 24/7 access to your care team, a personalized chronic care plan, and coordinated management of all your conditions, available as a covered Medicare benefit.
CCM is a Medicare-covered service, meaning eligible patients can enroll at little or no out-of-pocket cost.
What CCM Includes
A comprehensive set of services designed to keep patients with chronic conditions healthier and out of the hospital, proactively managed between appointments.
24/7 Care Team Access
Reach your HPG care team 24 hours a day, 7 days a week for urgent needs, by phone and other non-face-to-face methods such as email. Get help with urgent clinical questions, symptom guidance, and non-emergency concerns whenever you need it.
Personalized Care Plan
A comprehensive, individualized care plan developed with your specific health conditions, medications, goals, and preferences, updated regularly as your health status changes. Includes all diagnoses, medications, allergies, and care goals in one document.
Coordinated Care
We manage your care as you move between providers and settings: referrals to specialists, follow-up after an emergency room visit, follow-up after a hospital or skilled nursing facility discharge, and coordination with home and community-based providers. Nothing falls through the cracks.
Medication Management
Ongoing medication reconciliation, refill management, adherence support, oversight of your medications, and collaboration with our in-house pharmacist. We identify and resolve medication problems before they cause complications.
Routine Appointments
Get successive, routine appointments with your designated primary care provider or a member of your care team, so your chronic conditions stay actively managed between visits.
Preventive Care Scheduling
Timely scheduling of all recommended preventive care services as part of managing your chronic conditions, helping catch problems early and keep you healthier.
Common Chronic Conditions We Manage
CCM is available to patients with two or more of these (or other) chronic conditions expected to last at least 12 months.
Who Qualifies for CCM?
You or your loved one may qualify for HPG's CCM program if the following apply:
- You are enrolled in Medicare Part B
- You have two or more chronic conditions expected to last at least 12 months or longer
- You are at increased risk for serious health complications, worsening symptoms, or decline in daily functioning
- You are an established patient of Home Physicians Group
- You are willing to sign a CCM consent form to authorize enrollment
Ready to Enroll?
Enrollment is simple. Sign the CCM consent form and your care team handles the rest. Call us or complete the consent form online.
Spanish-language forms available. Acuerdo Servicio available upon request.
Better Chronic Care Starts with Better Coordination
HPG's CCM program is available to established patients with Medicare. Ask about enrolling today.