Chronic Care Management - Perlman Clinic

Chronic Care Management

Perlman Clinic believes that the best way to keep patients healthy in the long run is to focus on Chronic Care Management.  Chronic Care Diseases include:

Alzheimer’s disease and related dementia, Arthritis (osteoarthritis and rheumatoid), Asthma, Atrial fibrillation, Autism spectrum disorders, Cancer, Chronic Obstructive Pulmonary Disease, Depression, Diabetes, Heart failure, Hypertension, Ischemic heart disease, Osteoporosis and more.

Left uncared for, these diseases can lead to strokes, heart attacks and other life threatening medical emergencies.

That is why Perlman Clinic not only provides Chronic Care Management services to all of its patients, but it also participates in Medicare’s Chronic Care Management Program.

Services in the program include:

  1. Structured recording of demographics, problems, medications, medication allergies, and the creation of a structured clinical summary record, using a certified EHR – This and other activities requiring certified EHR technology (CEHRT) must be completed using the edition(s) of certification criteria that is acceptable for the EHR Incentive Programs as of December 31st of each calendar year preceding each PFS payment year


  1. 24/7 access to care management services – Providing the patient with means of timely contact with health care providers in the practice having access to the health record, to address urgent chronic care needs at all times


  1. Continuity of care with a designated member of the care team – Ability to obtain successive routine appointments with this individual


  1. Systematic assessment of health needs and receipt of preventive services ‒ Systematic assessment of medical, functional and psychosocial needs ‒ Systems based approaches to ensure timely receipt of all recommended preventive services ‒ Medication reconciliation with review of adherence and potential interactions ‒ Oversight of patient self-management of medications


  1. Electronic care plan – Creation/maintenance of comprehensive plan of care for all health issues that is patient-centered, based on a physical, mental, cognitive, psychosocial, functional and environmental assessment or reassessment, etc.


  1. Management of care transitions – Managing transitions between and among health care providers and settings including referrals to other clinicians, follow up after ER, and follow-up after discharge from hospital, skilled nursing facility or other health care facility – Create/format clinical summaries according to CCM certified technology – Transmission/exchange of summary care record using any electronic tool (other than fax)


  1. Coordination with home and community-based clinical service providers as appropriate – Communication to and from these providers must be documented in the EHR using CCM certified technology


  1. Enhanced communication opportunities for patient and caregiver – Communication with the practitioner regarding the beneficiary’s care through telephone, secure messaging, secure internet or other asynchronous non face-to-face consultation methods (subject to HIPAA)

If you would like to learn more about how Chronic Care Management can benefit you today, please call us at 858.554.1212 and one of our representatives will be happy to assist you.