CCM
Chronic Care Management
Our Care Management team may include nurses, community health workers, and other support staff who work with patients and providers to help coordinate care.
Family Medical Center of Michigan offers Care Management services to help patients better understand their health needs, manage chronic conditions, and connect with support that can improve overall well-being. Care management can be especially helpful for patients living with complex conditions such as diabetes, high blood pressure, heart disease, asthma, or other ongoing health concerns.
Our Care Management team may include nurses, community health workers, and other support staff who work with patients and providers to help coordinate care. Services may include chronic condition support, remote patient monitoring, medication and care plan education, follow-up after hospital or emergency department visits, and help connecting patients to community resources for needs such as food, transportation, housing, medication access, or other social drivers of health.
Family Medical Center also provides Transitional Care Management to support patients after an inpatient hospital stay or emergency department visit. Our nursing and community health worker teams can help patients understand discharge instructions, schedule follow-up care, review care needs, and reduce the risk of avoidable complications or readmissions.
Community Health Workers also play an important role in preventive care. They can help patients close care gaps by assisting with screenings, immunizations, annual wellness visits, follow-up appointments, and referrals to needed services. Through care management, our goal is to make healthcare easier to navigate and help patients feel supported between visits.
If your provider believes you may benefit from Care Management services, they will talk with you about how the program can support your health goals. Participation is encouraged because care management can help you stay connected to your care team, better manage your conditions, and receive support between visits for the best possible outcomes.
Call 734-654-2169 ext. 1421 today to see if you qualify!
Eligibility Requirements
Medicare CCM
If you have TWO or more chronic health conditions such as:
- Arthritis
- Diabetes
- High blood pressure
- Depression
- COPD
- Vascular Disease
Blue Cross Blue Shield (PDCM)
There are no eligibility criteria for Provider Delivered Care Management (PDCM) through Blue Cross Blue Shield
Care Management Staff
Roula M.
Certified Community Health Worker
Lori O.
LPN Nurse Case Manager
