Avenue Chronic/Complex Care Management

Living with multiple chronic conditions can be challenging, affecting one's quality of life and overall well-being. Designed for patients facing the complexities of two or more chronic conditions, Avenue's Chronic/Complex Care Management (CCM), provided by Sisselman Medical Group, provides comprehensive and person-centered care, empowering individuals to manage their health effectively. 

Keep reading to explore the key features and benefits of Avenue's CCM services and how they support patients with various chronic conditions.

Comprehensive Care for Chronic Conditions

Avenue's CCM program is specifically tailored for patients with chronic conditions expected to last 12 months or more or those at significant risk of adverse outcomes. The program extends its support to individuals with a wide range of chronic conditions, including but not limited to hypertension, diabetes, congestive heart failure, hyperlipidemia, chronic obstructive pulmonary disease, obesity, depression, cancer, osteoarthritis, and dementia. Avenue's CCM aims to improve patients' overall health and reduce the risk of complications.

Key Services Provided by Avenue's CCM

When it comes to the key services provided by Avenue’s CCM program, there are quite a few:

Comprehensive Assessments and Person-Centered Care Plans

Avenue's CCM program begins with thorough assessments, considering the unique needs and circumstances of each patient. Based on these assessments, personalized care plans are developed, taking into account the individual's chronic conditions, lifestyle, and goals. This person-centered approach ensures that the care provided aligns with the patient's preferences and enhances their engagement in their own health management.

Patient Education and Preventive Service Reminders

Education plays a vital role in empowering patients to actively participate in their care. Avenue's CCM services provide comprehensive patient education, covering disease processes, medications, and available community resources. Additionally, preventive service reminders are offered to ensure that patients stay up to date with their screenings, vaccinations, and other preventive measures.

Transition of Care Management

Transitions between different healthcare settings can be challenging, often leading to disruptions in care. Avenue's CCM program addresses this issue by offering transition of care management, facilitating a seamless transfer of information and coordination between healthcare providers. This ensures continuity of care and reduces the risk of complications arising from disjointed healthcare delivery.

RN Continuity and Care Coordination

Registered nurses (RNs) serve as crucial points of contact for patients enrolled in Avenue's CCM program. By fostering ongoing relationships and open communication, RNs ensure optimal patient and caregiver engagement and experience. They coordinate care and facilitate information exchange with specialists and other healthcare providers, promoting a collaborative and holistic approach to healthcare delivery.

Support for Lasting Health Behavioral Changes

Avenue's CCM services recognize the importance of addressing behavioral aspects of health. Using motivational interviewing techniques, healthcare professionals provide support to patients, empowering them to make lasting behavioral changes that positively impact their health. This approach goes beyond managing chronic conditions and focuses on promoting healthy habits and self-care practices.

24/7 Patient Access to Care and Health Information

Healthcare needs may arise at any time, and Avenue's CCM program ensures that patients have access to care and health information whenever they need it. By providing round-the-clock availability, Avenue's CCM program enables patients to seek guidance and support at any time, which enhances their peace of mind and overall well-being.

Comprehensive Reports and Patient Advocacy

Avenue's CCM program goes beyond patient care by providing comprehensive billing reports for practices. These reports assist healthcare providers in managing the financial aspects of care delivery. Furthermore, the program includes patient advocacy, which empowers patients to navigate the complex healthcare system and ensures their voices are heard.

Additional Avenue Health Coach Activities/Coordination/Referrals

Avenue's CCM program extends its support beyond the core services mentioned above. Health coaches actively engage with patients, coordinating various activities and referrals to address their specific needs. Some of these additional services include the following:

• Prescription Assistance, Medication Assistance Programs, and Co-Pay Assistance Programs: Health coaches assist patients in accessing affordable medications through prescription assistance programs and co-pay assistance programs.
• Transportation Coordination: Avenue's CCM program recognizes that transportation can be a barrier to healthcare access. Health coaches help coordinate transportation services, ensuring that patients can reach their healthcare appointments without difficulty.
• Advance Care Planning: Health coaches facilitate discussions on advance care planning, helping patients make informed decisions regarding their future healthcare preferences.
• Community/SDOH Resources: Health coaches connect patients with community resources to address social determinants of health, such as food insecurity, utility assistance, and housing assistance.
• PHQ9 Assessments: Health coaches conduct PHQ9 assessments to screen for depression and provide appropriate support and referrals.
• Dieticians, Specialists, and Nutritional Programs: Health coaches facilitate referrals to dieticians and specialists, enabling patients to access additional support for their nutritional needs.
• Medicaid Assistance/Social Worker: For patients eligible for Medicaid, health coaches provide assistance in navigating the application process and connecting them with social workers for comprehensive support.
• Senior Well-being and Senior Day Program: Avenue's CCM program recognizes the unique needs of seniors and offers specific programs to promote their well-being and provide opportunities for socialization.

Avenue's Chronic/Complex Care Management program is a comprehensive and patient-centered approach to managing multiple chronic conditions. By providing extensive support, education, care coordination, and advocacy, Sisselman Medical Group empowers patients to take charge of their health and improve their overall well-being. If you or a loved one are facing the challenges of managing multiple chronic conditions, Avenue's CCM program may be the support you need to lead a healthier and more fulfilling life. Contact us today if you have any questions!