Chronic Care Management (CCM) & Community Health Integration (CHI)

If you’re living with multiple chronic conditions, staying on top of your care can feel overwhelming. That’s where Chronic Care Management (CCM) and Community Health Integration (CHI) services come in. These Medicare-covered programs are designed to provide personalized, ongoing support to help you manage your health, stay out of the hospital, and improve your quality of life.

These services offer monthly support from a dedicated care team, connecting you to the care, resources, and education you need—all coordinated around your individual needs and goals.

What is Chronic Care Management (CCM)?

Chronic Care Management is a Medicare program for patients with two or more chronic conditions, such as:

• Diabetes
• Heart disease
• COPD
• Arthritis
• Hypertension
• Depression or anxiety
• Chronic kidney disease

With CCM, you receive ongoing, non-face-to-face care coordination between your office visits. This means a care team will help you stay on track with your health through:

• Monthly check-ins (phone or electronic)
• Medication management
• Help setting and meeting health goals
• Coordination between specialists
• Access to community resources and services
• Assistance with scheduling appointments and follow-ups

CCM is billed monthly to Medicare and may require a small copayment, though many patients have no out-of-pocket cost depending on their coverage.

What is Community Health Integration (CHI)?

Community Health Integration is a newer Medicare benefit designed to address the social needs that impact your health, such as:

• Transportation to medical appointments
• Food insecurity
• Housing or utility assistance
• Access to caregiving or support services
• Health education and coaching

Through CHI, a Community Health Worker or Care Coordinator helps you connect with the services and resources that support both your medical and social well-being. This holistic approach recognizes that your health depends on more than prescriptions—it depends on support, stability, and access.

Who is eligible?

You may qualify for CCM and/or CHI if you:

• Have two or more chronic conditions expected to last at least 12 months
• Are enrolled in Original Medicare (Part B)
• Are willing to consent to ongoing monthly care coordination services
• Need help navigating healthcare or accessing essential services in your community

These services are available in-person or by phone, depending on your needs and preferences.

Benefits of CCM & CHI

• Fewer emergency room visits and hospital stays
• Better medication adherence
• Increased confidence in managing your health
• Easier communication between your providers
• Support for both medical and non-medical challenges