Chronic and Transitional Care Management
Chronic Care Management
Discover Our Chronic Care Management Program for a Healthier Future
We understand the challenges of living with chronic conditions and are here to support you every step of the way. Chronic Care Management (CCM) is a proactive approach to keep you connected with your health care provider, make your health care journey more manageable, and improve your overall well-being. If you have Medicare B and two or more chronic conditions expected to last 12 months or longer, you may be eligible for CCM.
Through our CCM program, you’ll receive care from a dedicated Medical Assistant who will work closely with you and your health care provider to develop a personalized care plan tailored to your specific needs and goals. They will be your partner in care, overseeing and coordinating your health care to ensure you thoroughly understand all aspects of your conditions, medications and treatment plans.
Take control of your health today and inquire with your primary care provider about enrolling in our Chronic Care Management program at Gritman Medical Center. We’re here to guide you toward a healthier and more fulfilling future.
Talk to your provider or call our Chronic Care Management team:
- 208-997-1402
Hours: Monday – Thursday, 8 a.m. to 5 p.m.
Transitional Care Management
Supporting Your Safe Recovery After a Hospital Stay
Transitional Care Management (TCM) helps Medicare patients safely transition from the hospital, skilled nursing facility or rehabilitation center back home. Our care team provides follow-up care, medication review and care coordination to support your recovery and help reduce the risk of hospital readmission.
You may be eligible for our Transitional Care Management program if you:
- Recently left a hospital, skilled nursing facility or rehabilitation center
- Have Medicare coverage
- Need follow-up care, medication management or help coordinating your recovery
After you are discharged, our care team will:
- Contact you within 2 business days
- Schedule a follow-up visit within 7–14 days
- Review your medications and care plan
- Coordinate care with your specialists and other providers
- Answer questions and support your recovery needs for 30 days post-discharge
Talk to your provider or call our Transitional Care Management team:
- 208-997-1402
Hours: Monday – Thursday, 8 a.m. to 5 p.m.
