Chronic Care Management
We are here to help you live a healthier life, for longer.
As a member of our Chronic Care Management Program, you will be assigned a care coordinator who will schedule check-in calls throughout the year (frequency dependent on evaluation) and assist you with all your healthcare needs.
Assist in managing your appointments
Provide you with a direct line to a nurse or care coordinator
Coordinate home health or medical equipment needs
Answer general healthcare questions
Help with medication refills or explain how and when to take your medications
Coordinate with other doctors and members of your care team
Connect you with any community resources, if applicable
Who is Eligible?
This program is for Medicare patients with more than one chronic condition such as, diabetes, hypertension, COPD, sleep apnea, cardiovascular disease, kidney disease, and many others.
If you are interested in enrolling, please contact us and we’ll be happy to get you started.
Why Enroll?
We are here to help you navigate the complex world of healthcare by removing barriers with nurse check-in calls and updates to your healthcare provider about any new developments. As a member of the program, you will have a direct line to a nurse for any questions or concerns that may arise.
Every patient’s care plan is unique, and we customize the frequency of check-ins based on your needs. Check-ins can be scheduled weekly, monthly, or quarterly. Once you are enrolled, you will work with our care coordinator to establish the best plan for you.
Cost & Coverage
This service is covered by Medicare and is subject to your annual deductible and coinsurance (usually 20%). If you have a secondary or supplemental insurance plan, your coinsurance may be covered. Please call your insurance representative for more information.
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Medicare Enrollment Facts & Resources
Medicare enrollment begins Oct. 15, 2024, through Dec. 7, 2024. Make sure you have all the facts about your coverage options and possible limitations before getting locked in for the year.
Medicare Advantage Plans Disrupting Care for Rural Seniors
Get the Facts Before Committing to Medicare Advantage
CMS Open Enrollment Resources
Leveling the Playing Field for Rural Seniors & Hospitals
Additional Resources
Accountable Care Organization (ACO)
CMS Learn more about ACO Medicare
AACOG Benefits Counseling
Methodist Healthcare Ministries
Medina Center Meals on Wheels
Castroville FBC Pantry
Devine Food Pantry Ministry
Hondo Medina Country Food Pantry
The San Antonio Food Bank
Schedule an appointment today
Whether you're in need of a routine check-up or specialized treatment, our experienced healthcare professionals are here to provide quality care close to home.
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