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Understanding Chronic Care Management (CCM)
Chronic Care Management (CCM) is a comprehensive approach to supporting patients with two or more chronic conditions, such as diabetes, hypertension, heart disease, COPD, arthritis, or kidney disease. These long-term conditions require continuous monitoring, coordination, and lifestyle support to prevent complications and improve daily well-being.
At Baytown Internal Medicine, we understand the challenges that come with managing chronic illnesses. Our CCM program is designed to help you stay in control of your health, reduce hospital visits, and maintain a better quality of life. Through ongoing check-ins, personalized care planning, and medication management, we act as your dedicated partner in long-term wellness.
Who Can Benefit from CCM?
If you’re living with multiple chronic conditions that are expected to last 12 months or more, you may qualify for our Chronic Care Management services. This includes common diagnoses such as:
Type 2 Diabetes
Hypertension
Congestive Heart Failure
Asthma or COPD
Osteoarthritis
Depression or Anxiety
Chronic Kidney Disease (CKD)
Patients enrolled in our CCM program receive monthly follow-ups, medication reviews, and coordination between specialists. You’ll also have access to a care coordinator who helps ensure nothing slips through the cracks whether it’s test results, appointments, or refills.
How Baytown Internal Medicine Supports You
Our CCM service goes beyond routine office visits. We take a proactive approach to care, with services that may include:
Development of a personalized care plan
Regular phone check-ins and health coaching
Coordination with specialists, labs, and pharmacies
Assistance with medication adherence and prescription refills
Monitoring of vitals and symptoms to catch issues early
24/7 access to clinical support for urgent needs
Our goal is to reduce emergency room visits, prevent unnecessary hospitalizations, and keep you on track with your treatment plan. All services are delivered with compassion, professionalism, and a deep understanding of your unique health needs.
Why Choose Baytown Internal Medicine for Chronic Care?
Patients trust Baytown Internal Medicine because we treat chronic conditions with consistent attention, not just occasional appointments. Our team takes time to listen, understand your health goals, and provide the guidance and accountability you need to stay well. We work closely with Medicare and other insurers to ensure CCM services are accessible and affordable.
With decades of combined experience and a patient-first philosophy, we are committed to helping you thrive not just manage. If you’re ready for a better way to manage your long-term health, ask us how our Chronic Care Management program can support you today.
