Chronic Care Management (CCM) Program

Providing the Care You Need Between Visits


We’re Here to Help

By registering for our Chronic Care Management (CCM) program, you will have access to all the help you need to manage your chronic disease(s). Using a team-based approach, we help you understand your diagnoses, assess your needs, and create care plans that help you reach your health goals. When you’re enrolled in CCM, you will have direct access to a healthcare professional 24/7/365 through our Nurse Advice Line.


To qualify for CCM enrollment you must:

  • Have 2 or more chronic conditions
  • Have Medicare Part B

How The Program Works

You’ll work with our clinic team members in between your regularly scheduled visits with your doctor, to create personalized care plans around your health goals. Topics for discussion will likely include:

  • lifestyle changes
  • medications and care instructions
  • introduction to community resources
  • addressing barriers 
  • coordination of care

We believe that by using our entire team to care for our patients, we can provide a more holistic and personalized approach to the treatment of chronic conditions. By providing these between visits with your doctor, CCM will enable us to create a tailored care plan that changes as frequently as you need.

What Are Chronic Conditions?

Chronic conditions, or chronic diseases, are medical diagnoses that are long-lasting. The word “chronic” is used when the disease or condition lasts for one year or more. Chronic diseases are very common and require frequent medical attention. Six out of ten adults in the United States have a chronic disease, and four out of ten adults have two or more chronic diseases. 

Some of the most common chronic disease diagnoses include (but are not limited to):

  • Diabetes
  • Chronic Kidney Disease
  • Cancer
  • Arthritis
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Heart Disease
  • Obesity

We Want to Help!

Register for our Chronic Care Management (CCM) program today.

(254) 865-2166

Meet the CCM Team

Kayla Chumley BSN, RN – Care Coordinator

(254) 248-3204

Maci Bourgeois, LVN – Assistant Care Coordinator

(254) 248-3210