Sometimes the key to long-term health is follow-up.

A phone call with a gentle reminder or a check-in to make sure questions are answered can keep a patient (and the patient’s family) on track with what their doctor has recommended.

That’s the work of our Chronic Care Management team. They pick up where the doctor leaves off and check in with patients soon after they leave the hospital.

“We are an extension of the primary care provider’s office. We’re another layer of support and care,” says Heather Marini, System Supervisor Population Health Management.

Chronic care managers make sure their patients are following their doctor’s plan of care, whether it’s improving their diet or lowering their blood pressure.

To be eligible for chronic care management, a patient must meet two or more qualifying conditions and be on Medicare. Patients typically receive a referral for chronic care management from their doctor.

Many chronic care management patients are elderly. Certain patients, if they’re frequently in and out of the hospital and don’t have Medicare, receive help too.

“We find out what’s important to the patient and create goals based on that,” Marini says. “It helps them form habits. They might not be used to doing something, so we call them monthly and help keep them focused on those goals.”

Without this important follow-up, many patients may lose track of their treatment plans and end up hospitalized again.

“A lot of patients feel like they’re a burden on their family so they at least have us to call if they have questions,” says Ashley Carlson, medical assistant and health coach. “Sometimes I’ll call a patient and you can tell they’re in the middle of a cold. If they had let it go longer, they could have had an admission to the hospital. We’ve cut back on that a lot.”

While it may be a relatively unknown service we provide, chronic care management is an essential tool we use to help our patients stay on course for good health.