Chronic Care Management for Medicare Beneficiaries

The National Center for Health Equity (NCHE) offers localized care coordination services for clinics serving at risk Medicare beneficiaries.

Designed to Augment and Support Care Providers

Focusing on diverse areas such as the Bronx in NYC.

NCHE offers a complete turnkey end-to-end Chronic Care Management service compliant with U.S. Department of Health and Human Services (DHSS), and Centers for Medicare and Medicaid Services (CMS).

Most community health centers need the holistic approach that solves the staffing issues most boroughs have by utilizing local, credentialed nurses that work as independent contractors.

These RNs are equipped with localized cultural awareness and sensitive engagement necessary to collaborate with patients proactively while allowing in-house staff to work on more acute matters.

A methodology to improve patient outcomes

This will benefit the entire patient population while increasing access to care and health equity.

While, of course, bolstering clinical reimbursement from Medicare and potentially Medicaid.

The NCHE service includes standard operating procedures that correlate directly to the process and procedure documentation at each clinic.

The nurses track care outcomes with a HIPAA compliant system and workflows that support end-to-end quality and compliance for all clients. With nationally recognized CCM subject matter expertise, once clinics join the NCHE CCM national network, each program is continuously improved with optimizing patient outreach and engagement, utilizing key therapeutic area strategies for better patient outcomes and reporting, while importantly developing a more sustainable program with greater reimbursement for the clinic.

Chronic Care Management Program

The CCM program includes the entire range of CMS programs

Chronic Care Management

Nurse-led care coordination services focusing on CMS Medicare Chronic Care Management program patient engagement, tracking and coordination with primary clinic, primary general practitioner and other staff in the clinic.

Principal Care Management

Nurse-led care coordination services focusing on CMS Medicare Principal Care Management program patient engagement, tracking and coordination with specialist clinics, specialist physicians and other staff in the clinic.

Behavioral Health Integration

Nurse-led care coordination services focusing on CMS Medicare Principal Care Management program patient engagement, tracking and coordination with primary clinics involved in the coordination of psychiatric services.

Remote Physiological Monitoring

Service offering tailored to specific devices, therapeutic areas and programs. Our Chronic Care Management platform comes with open APIs and supports RPM devices developed to open standards.

Transitional Care Management

Nurse and other health care professional led service supporting

Capitalize on flexible, locally focused, multicultural sensitive CCM services via a true-team-based approach.

Contact the NCHE to learn more about CCM for your clinic today.

Improve patient outcomes in diverse, communities of color

Augment and boost local clinic revenues thanks to CMS and other payer reimbursement

Ensure compliance with CMS rules and policies

Ramp up fee for value programs without need to hire new staff