WHITEPAPER: CCM Collaborative Care

Collaborative Care - The Key to Effective Chronic Care Management

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Most people think of collaboration as just being between the patient’s PCP and other levels of physician care, such as specialists or hospital-level care. However, physician practices have several care team members– front and back office staff, medical assistants, nurses, and, of course, the providers.

Disconnects between the patient’s PCP, specialists, and hospital care team created huge gaps that often resulted in disjointed care that affects the patient’s overall outcome.

From a chronic care perspective, the pharmacist, lab and diagnostic providers, as well as home care nurses and therapists, hospice staff, family members, and many other community resources that help support patients at the primary care level must be included.

This whitepaper will discuss these gaps and how to fill them in a collaborative manner to maximize CCM program success.

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