Chronic Care Management
Contact Your Care Team
If you have questions about your chronic care services or would like to speak with a coordinator,
please reach out to our CareHarmony partners directly:
CareHarmony Support Line: (785) 890-4070
Our providers remain your primary medical team and maintain ultimate responsibility for your care.
CareHarmony is here to ensure that care never stops.
How the Program Works
If you have two or more chronic conditions (such as diabetes, high blood pressure, COPD, or heart
disease), you may be eligible for this specialized service.
- 24/7 Access: You gain round-the-clock access to clinical staff to address urgent needs, helping you avoid unnecessary ER visits and hospitalizations.
- Monthly Check-ins: Each month, a care coordinator will spend at least 20 minutes working on your behalf—monitoring your symptoms, tracking your health goals, and reconciling your medications.
- A Unified Care Plan: CareHarmony works directly with your Goodland Family Health Center provider to create a "single source of truth" for your medical care. Any changes in your health are reported to your provider immediately
Enrollment & Eligibility
Medicare and other insurance providers recognize the importance of continuous care. Here is how to
get started:
- The Initial Visit: To begin, Medicare requires a face-to-face "initiating visit" with your provider (this can be your Annual Wellness Visit or a regular check-up). If you have seen your provider within the last year, enrollment can often be completed over the phone.
- Informed Consent: The CareHarmony team will explain the program in detail, including the 20% co-insurance requirement (standard for Medicare services).
- Your Choice: Participation is completely voluntary. You have the right to opt-out of the program at any time.
- Continuous Support: A steady relationship with a designated member of your care team.
- Expert Coordination: Help managing transitions of care, such as after a hospital stay or when visiting specialists.
- Proactive Education: Personalized resources to help you and your caregivers better understand and manage your health conditions.
Centers for Medicare & Medicaid Services (CMS)
The Centers for Medicare & Medicaid Services (CMS) recognizes the importance of taking care of the patient all of the time, not just at the point of care. Therefore, CCM services are typically provided outside of face-to-face patient visits and focus on.
- A continuous relationship with a designated member of the CCM team
- Support for chronic diseases to achieve health goals
- 24/7 patient access to care and health information
- Preventative care
- Patient and caregiver education and engagement
- Timely sharing and use of health information
- Medication reconciliation
Initiating Visit
Medicare requires initiation of CCM services to take place during a face-to-face visit with your healthcare provider (physician, certified nurse midwife, clinical nurse specialists, nurse practitioners and/or physician assistants). This can be during an annual wellness visit, initial preventative physical exam or other face-to-face visit for new patients or patients not seen within one year prior to the commencement of CCM services (the initiating visit is not part of the CCM service and is separately billed). Otherwise, enrollment of eligible beneficiaries may take place by phone.
Common Chronic Conditions (Among Medicare Patients)
- Alzheimer’s and Dementia
- Acquired Hypothyroidism
- Heart Failure Depression
- Chronic Kidney Disease
- Cataracts
- Anemia
- Diabetes
- Ischemic Heart Disease
- Rheumatoid Arthritis
- Osteoarthritis
- Hyperlipidemia
- Hypertension
- Stroke
- Cancer
- Substance Addiction