Chronic Care Management

Let’s presume the starting point for a particular individual’s engagement with a Chronic Care Management program begins after transition from an inpatient stay back to home. As a part of the care transition process, the individual, optimally, is in possession of their healthcare record and understands their health status upon discharge. Using this baseline, the Chronic Care Management team can begin the long term job of keeping that individual in the community and avoiding acute events.

The core job of the Chronic Care Management team is to provide the extensive and ongoing supports required to help the patient and their caregivers handle obstacles that arise and have the potential to result in an exacerbation of their chronic condition. Success is measured in improved health and quality of life, reduced hospitalizations and ER visit, reduced duplication of diagnostic tests and decreased overall medical expenses.

The caseload management approach utilized by Pyramid Home Health services’ regional care teams, MSW/ LCSW, RN and MTM certified pharmacist coupled with para- professional care givers is a model that lends itself perfectly to the cause of Chronic Care Management. These teams are skilled in disease specific patient education. They actively manage the inflow of information from medication screens, tele-monitoring devices in patient’s homes and family caregivers and react as necessary. Where acute incident seem to be developing they communicate effectively with the patient’s broader medical team, intervene as necessary and stop the advancement of symptoms that can lead to the ER or a hospitalization.

Notwithstanding the capability of our credentialed team members, Chronic Care Management is not solely the responsibility of credentialed clinicians. For example, many chronically ill individuals know what they should be doing to control their disease(s). Many just don’t do it or they need help doing things like checking their insulin, remembering to weigh daily, take medication and make physician appointments. Sending a trained clinician to the home of these individuals daily to help with these sorts of issues is simply not cost effective over the long term. Sending one of Pyramid Home Health Services’ Para-professional care givers, utilizing our automated medication reminder call program, multi-dose medication packaging, pre-scheduling services for physician visits and assistance arranging transportation is. Matching the appropriate support and assistance to the most cost effective deployment thereof is an important part of an effective Chronic Care Management program.

Pyramid Home Health Services provides HCBS, Home Health and Pharmacy services for a large population of Missourians residing in both rural and urban areas. Our Care Management teams effectively serve patients in 110 Missouri counties daily. Should you require assistance implementing a Chronic Care Management Program or require the same for a family member, patient or patient population contact Pyramid Home Health Services at 888-880-6565 or visit us at

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