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Understanding Medicare's Care Coordinating Program

Medicare’s Care Coordinating Program is a unique program that helps people with chronic conditions live longer, healthier lives. These programs are designed to help patients manage their health and finances throughout their lifetime while providing the care they need. In this article, we will explore four programs offered by Medicare: Advanced Care Planning (ACP), Behavioral Health Integration (BHI) Chronic Care Management (CCM), and Transitional Care Management (TCM).

Advance Care Planning (ACP)

Advance Care Planning (ACP) is a voluntary program that helps people with serious illnesses or injury to plan for their future medical care. ACP can help patients and their families understand the benefits of advance directives, or living wills, which give consent-based instructions on how you would like to be treated in an emergency situation. You can also use this information to create an advance directive if you don't already have one.

It is an important step that you can take to ensure that your values and wishes will be honored in case you become too sick to speak for yourself. This includes discussing these topics with family members, friends, and healthcare providers.

In general, there are two types of advance directives: living wills (also called "advance directives") and health care proxies (also called "medical power of attorney"). A living will states what medical treatment you want or don't want if certain conditions arise during your lifetime; it also outlines any other special requests related to life-sustaining procedures such as CPR or organ donation. A health care proxy allows another person—such as a spouse—to make decisions on your behalf when they know you're incapacitated due to illness or injury so that they can ensure quality end-of-life care has been provided at the end.

Behavioral Health Integration (BHI)

Behavioral Health Integration (BHI) is a program that helps people with behavioral health conditions. It provides access to behavioral health services, support for those with mental illness and substance use disorders, as well as community resources if needed.

BHI is not mandatory for patients; however, it can be helpful in managing your care. The program does not cover emergency room visits or hospital stays but does provide support for caregivers or family members who may need assistance during this time period. The goal of BHI is to improve communication between providers and patients/caregivers by providing support during appointments; following through with treatment plans; accessing community resources if needed; improving access to care through telehealth technology like video-conferencing systems which allow you to see doctors remotely without having them come into your home town every month.

BHI is a team-based model consisting of a primary care physician, a care manager, and consulting psychiatrist who work together to provide coordinated treatment plans for eligible members. The team often includes other professionals such as social workers or mental health counselors as well as members from each member's family unit if needed.

Chronic Care Management (CCM)

Chronic Care Management (CCM) is a coordinated approach provided to Medicare patients who have two or more chronic conditions. Service practitioners, including clinical pharmacists and other non-physician practitioners, can bill for this service. Supervision is required by the supervising physician who should be in close proximity and/or available on a regular basis. The patient must be given the opportunity to opt-out of the service before they receive it; this is an important step towards improved health outcomes for all patients receiving CCM services.

CCM services may include:

  • Arranging for referrals for specialty care;

  • Monitoring medications;

  • Managing pain management and other health issues related to your condition(s);

  • Providing education on how to manage your condition(s).

Who Is Eligible For CCM?

To be eligible for chronic care management, you must:

  • Have multiple chronic conditions (2 or more) that are expected to last at least 12 months or until death and/or those who are at significant risk of death, acute exacerbation, or decompensation.

Transitional Care Management (TCM)

Transitional Care Management (TCM) is intended to help patients and their families manage their care after discharge from the hospital. It can also be very helpful if you have a mental illness or a disability.

TCM services may be provided by a variety of providers, including primary care physicians, specialists, and nurse practitioners. These providers are often referred to as “primary care” clinicians because they have traditionally been the first line of treatment for patients with chronic conditions or conditions that require ongoing monitoring and support in order to maintain quality of life. These include a plan of care, patient education, and follow-up. It also includes a care team that includes the patient and their family.

TCM can be provided in a variety of settings including home, hospital, or nursing home. The TCM team works together with each patient to ensure they are actively involved in their care across all aspects: from setting goals for treatment and monitoring progress, to developing plans for safety when home alone or visiting family members after being discharged from the hospital.

TCM is an important part of the transition process for both providers and patients, but it's also important for long-term healthcare planning. TCM helps you keep track of what your loved one needs and how they'll receive those services once they leave your facility. You may want to consider creating a TCM if:

  • Your loved one has had surgery or other medical procedures at another hospital in the area

  • Your loved one lives far from home and needs help getting there

In order to reap the benefits of these programs, individuals should begin researching their options and communicating with their doctors about their plans for the future. The more information you have, the easier it will be to make informed decisions regarding your health care needs. This will likely help to ensure that your medical professionals are aware of your wishes and that they can adequately respond to any situations that may arise in the future.

With this information, you can decide whether or not one of these programs might be right for you.

If you have questions about your coverage or eligibility, please contact us at 601.863.0258 or send an email to We’re here to help!

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