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.

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