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.
Why CCM? Because Prevention Pays
- Stay ahead of the curve – Monthly check-ins and 24/7 support help catch flare-ups early—before they turn into ER visits or hospital stays.
- Feel seen, always – Personalized care plans coordinate your meds, appointments, tests, and specialists—so nothing slips through the cracks.
- Save time & money – CCM can reduce avoidable ER visits and hospitalizations, saving money for both families and the healthcare system.
What Makes Our CCM Program Stand Out
- Structured & Evidence-Based Approach: Created around the well-known Chronic Care Model, goal-setting, remote communication, care coordination, and self-management support.
- Team-Based Approach: Physicians, nurses, behavioural health consultants, and pharmacists work behind the scenes to create better outcomes and more satisfied providers.
- Billing You Can Trust: Medicare-approved—non-face-to-face services covered under CPT codes like 99490/99491 and levels of complex CCM for higher needs—with transparent cost structure.
- Telehealth & Remote Monitoring Ready: Your care goes where you go—whether video check-ins, digital data tracking, or chatbot reminders. RPM further produces better outcomes in COPD, hypertension, and diabetes.
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 and 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, when something feels “off,” mount CCM priority offers you access to our care team, wherein all issues will be resolved and you wouldn’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 important 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.