Avenue Chronic/ Complex Care Management

Avenue’s Chronic/Complex Care Management (CCM)is a program designed for patients with two or more chronic conditions expected to last 12 months or more or place them at significant risk of death, acute exacerbation/decompensation, or functional decline. The most common chronic conditions we support are: HTN, Diabetes, CHF, Hyperlipidemia, COPD, Obesity, Depression, Cancer, Osteoarthritis and Dementia.

Avenue’s CCM services provide:

• Comprehensive assessments and person-centered care plans
• Patient education (disease process, medication, community resources)
• Preventive service reminders
• Transition of care management
• RN continuity for optimal patient and caregiver engagement and experience
• Care coordination and information exchange with Specialists and other providers
• Support using motivational interviewing techniques to affect lasting health behavior change
• 24/7 patient access to care and health information
• Provide patients and or caregivers with copy of the care plan
• Comprehensive billing reports for practice
• Patient advocacy

Other Avenue Health Coach Activities/Coordination/Referrals:

• Prescription Assistance, Medication Assistance Programs and Co-Pay Assistance Programs
• Transportation coordination
• Advance Care Planning
• Community/SDOH resources -good insecurity, utility assistance, housing assistance
• PHQ9 Assessments
• Dietician, specialists, nutritional Programs
• Medicaid Assistance/Social Worker
• Senior well-being and senior day program

While CCM services are covered by many insurance plans, some plans may require a small co-pay.