Medicare patients with two or more chronic conditions can benefit from our Chronic Care Management Program. This is a personalized partnership with your healthcare team to develop an individualized care plan to help you manage your conditions, coordinate resources, and remove barriers so you can reach your healthcare goals.
Conditions list
Chronic care management is available for these and other conditions:
- Alzheimer’s disease and related dementia
- Arthritis
- Asthma
- Atrial fibrillation
- Cancer
- Cardiovascular disease
- Chronic obstructive pulmonary disease (COPD)
- Depression
- Diabetes
- Hypertension (high blood pressure)
Candidates for the program
Talk to your primary care provider to see if chronic care management is right for you. You can enroll during a regular appointment, including your annual Medicare Wellness Visit. The Chronic Care Management program partners with primary care providers at all Southeast Iowa Regional Medical Center primary care clinics in Fort Madison and West Burlington, including Family Medicine and Internal Medicine, to offer patient navigators.
Once enrolled, a personalized care plan will be created to support your health needs. You’ll have regular check-ins with a care coordinator who will help monitor your progress, adjust your care plan, coordinate services, and answer any healthcare questions.
Care coordinators connect with patients by phone after enrollment. While there is a charge for the service, many patients with secondary insurance or Medicare often have no out-of-pocket costs.
Patients can connect to the program by calling the care coordinators directly or talking to their PCP. Fort Madison’s patient navigator can be reached at 319-376-2748 and West Burlington is 319-768-1560. To learn more about the providers and clinics, visit Internal medicine | Great River Health and Family medicine | Great River Health.
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