CCM Transitions of Care

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.

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