CCM Transitions of Care

(Last Updated On: March 1, 2019)

Chronic Care Management patients are unfortunately often high utilizers of the emergency room and frequently hospitalized. Accordingly, a critical component of Chronic Care Management is managing care transitions between and among health care providers and settings, including referrals to other providers, including providing follow-up after an emergency department visit, and after discharges from hospitals, skilled nursing facilities, or other health care facilities. Alternatively these transitions can be managed under a Transitional Care Management program.