What Is Chronic Care Management?
Chronic Care Management (CCM) is a structured approach to support patients living with long-term health conditions. At Triangle Primary Care Associates, we focus on improving quality of life by providing continuous, coordinated care beyond traditional office visits. CCM ensures that patients receive the proper treatment, stay on track with medications, and benefit from a personalized care plan designed to prevent complications and hospitalizations.
What Is a Chronic Condition?
A chronic condition is a health issue that lasts for a year or more and requires ongoing medical attention or limits daily activities. Examples include diabetes, high blood pressure, heart disease, asthma, arthritis, and chronic kidney disease. Unlike short-term illnesses, chronic conditions often progress slowly and can impact overall well-being if not carefully managed. At Triangle Primary Care Associates, our team helps patients manage these conditions with long-term support and care.
Why Chronic Care Management (CCM)? Because Prevention Pays
At Triangle Primary Care Associates, proactive care is the key to healthier lives. Our Chronic Care Management (CCM) program is designed to support patients with ongoing health conditions through regular check-ins, personalized care plans, and continuous monitoring. By focusing on prevention, we help reduce emergency visits, lower healthcare costs, and improve overall well-being.
Prevention doesn’t just protect health—it pays off in fewer hospital stays, stronger patient outcomes, and lasting peace of mind.
What Makes Our CCM Program Stand Out
At Triangle Primary Care Associates, our Chronic Care Management (CCM) program is more than routine follow-ups—it’s comprehensive, personalized care designed to make a real difference.
Personalized Care Plans – Every patient receives a tailored plan that addresses their unique health needs, lifestyle, and goals.
Regular Check-Ins – We stay connected through monthly calls and consistent monitoring to ensure health stays on track.
Coordinated Care – Our team works closely with specialists, hospitals, and other providers to keep care seamless and stress-free.
Focus on Prevention – We don’t wait for problems to arise; we identify risks early and act before they become emergencies.
Patient-Centered Approach – You’re never just a number. We listen, we guide, and we empower you to take charge of your health.
With CCM at Triangle Primary Care Associates, prevention becomes peace of mind—and better health becomes your everyday reality.
What Are Chronic Care Management Services?
Chronic Care Management services provide patients with consistent support to manage their long-term conditions effectively. At Triangle Primary Care Associates, these services include:
- Creating and maintaining a personalized care plan
- Coordinating with multiple healthcare providers
- Reminders for medications and follow-up appointments
- Regular monitoring of health status
- Education and guidance to encourage healthier lifestyle choices
By choosing CCM services at Triangle Primary Care Associates, patients can reduce the risk of emergency visits, gain better control of their health, and feel more supported in their daily care journey.
What CCM Looks Like at Triangle
1. One-On-One Kick-off
We commence with an all-inclusive session in-person or via telehealth. Together, we will create a care plan ideal for you, considering factors like your health goals, medications, lifestyle, and support system.
2. Monthly Proactive Care
Your team, provider, and nurse coordinator keep track of key metrics for 20-60 minutes a month, guide you through lifestyle changes, and adjust your care plan as necessary.
3. Easy Engagement Between Visits
Something about medications? Need to have bloodwork scheduled? Want some tips on eating or exercising? We are all ears via a phone call, a portal, or secure e-mail.
4. Urgent Access Around the Clock
Following hours, if you feel “off,” our CCM priority offers access to our care team, where all issues are resolved, and you won’t feel alone or overwhelmed.
5. The Easy Way to Coordinate Care
We handle communication with specialists, pharmacies, labs, rehab, or home health so that you can prioritize the most critical thing—feeling great.
Follow-Up & Return-To-Primary-Care
Stable patients return to primary care with continued support, and those with more complex issues remain within the neurology care pathway.
Chronic Care Management at Triangle Primary Care Associates
When life’s conditions are more than occasional, your care shouldn’t be either.
At Triangle Primary Care Associates, our Chronic Care Management (CCM) program is more than a service—it’s your partner in long-term health. For patients living with two or more chronic conditions (like diabetes, hypertension, COPD, or arthritis), our CCM team is here every day, helping you live better, not just longer.
