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How Chronic Care Management Improves Healthcare for Patients with Multiple Conditions

Navigating the maze of chronic health conditions can often feel like venturing into uncharted territory – with every step, there’s a new layer of uncertainty and complexity. However, despite all the challenges, there are also opportunities for transformative care and support.

At Syracuse Area Health (SAH), we understand the intricate dance between managing multiple chronic conditions and maintaining a happy, fulfilling life. Our Chronic Care Management (CCM) program, led by Care Coordinators Nikki Wenzel and Becky Pohlman (RNs), is designed to provide patients with an extra layer of personalized care, support, and guidance.

Subject to insurance approval, eligibility is open to all patients with a chronic health condition like arthritis, cardiovascular disease, COPD, diabetes, anxiety, depression, hypertension, cancer, and more.

There are a number of ways this CCM program makes a profound impact on patients’ experiences and assists them in managing multiple serious health conditions.

Care Coordination

One of the pivotal roles of our Care Coordinators through the CCM program is that of liaisons between patients and their healthcare providers. Both of these Care Coordinators work closely with assigned providers, ensuring seamless coordination of appointments, procedures, lab work, specialist consultations, and more.

“It’s an extra set of hands, eyes, and ears that help patients with more one-on-one care to help manage their chronic conditions,” said Wenzel.

Whatever the patient’s specific conditions, the CCM program can help with moving through the healthcare landscape effectively.

Enhanced Communication

Central to the success of CCM is the establishment of open and efficient communication channels. SAH’s Care Coordinators foster trust and a good rapport with patients, ensuring they feel comfortable reaching out for updates, sharing their concerns, seeking guidance, or asking questions about their healthcare.

“We work very closely with providers, and we help triage as needed, based on symptoms,” explained Pohlman. “If a patient doesn’t understand results from a certain test or anything else, we’ll provide an explanation and can talk them through their next-step options.”

With a direct and easy line of communication like this, responses are more timely, and additional trust is built between patients and providers.

Health Record Updates

CCM involves meticulous maintenance of patients’ health records, ensuring they are up-to-date and accurate at all times. Both Pohlman and Wenzel work diligently to ensure these records are correct and comprehensive, so patients have a clear understanding of their health status.

Symptom Management

SAH’s CCM program also includes robust symptom management strategies that are aimed at alleviating discomfort and improving overall well-being. Services such as diabetes management and medication compliance play critical roles in helping patients manage their multiple health conditions from home.

Comprehensive Care Management and Care Plan

Perhaps the cornerstone of CCM is the development of comprehensive care plans that are tailored to each patient’s unique health concerns and needs. SAH’s Care Coordinators collaborate closely with a patient’s healthcare providers to come up with personalized care plans. These plans encompass everything from medical interventions and lifestyle modifications to support strategies, medication plans, and more. With a proactive, whole-person approach, patients receive the care they deserve and can get back to living their lives despite their respective chronic health conditions.

Getting Started with Chronic Care Management at SAH

The CCM program at SAH exemplifies a commitment to patient-centered care. Through the dedicated efforts of SAH’s Care Coordinators, those living with multiple chronic conditions can be empowered with the resources, support, and guidance they need to improve their healthcare journey – so they can get back to doing what they love.

If you are grappling with the challenges of managing chronic health conditions, we encourage you to reach out to your family practice provider and ask them if the CCM program may be a good fit for you. You can also make an appointment with a family practice provider at either of our two SAH clinics – Syracuse Clinic or North Campus Clinic. Please note, provider referrals are required to get enrolled in the CCM program.

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