We’ve got your ongoing care needs covered.
For our residents with chronic care needs, we offer close-to-home, high quality care management.
If you have Medicare and live with two or more chronic conditions like arthritis, diabetes, depression, or high blood pressure, chronic care management services can help connect the dots so you can spend more time doing what you love.
Services may include:
We work with you to make sure medications are appropriate and not contraindicated and that any rehab or ongoing treatment needs are being met. We offer outpatient IV and antibiotic therapy, including central line and port access.
During a monthly 20-minute phone call, we make sure your care needs are coordinated, managed and met.
Preventive Visit & Yearly Medicare Part B
(Medical Insurance) Coverage
This visit includes a review of your medical and social history related to your health and education and counseling about preventive services, including:
- Height, weight, and blood pressure measurements.
- A calculation of your body mass index.
- A review of your potential risk for depression and your level of safety.
- An offer to talk with you about creating advance directives.
- A written plan for the screenings, shots, and other preventive services you may need.
- Developing or updating a list of current providers and prescriptions.
- Detection of any cognitive impairment.
FAQs
Chronic Care Management (CCM) is a Medicare-covered service that provides ongoing care coordination for patients with two or more chronic conditions. CCM helps manage medications, coordinate care between providers, and support patients between office visits to improve long-term health outcomes.
You may qualify for CCM if you:
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Have Medicare Part B
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Live with two or more chronic conditions expected to last at least 12 months
Common conditions include diabetes, high blood pressure, heart disease, arthritis, depression, and other long-term health conditions.
CCM services include:
- At least 20 minutes per month of care coordination
- A personalized care plan
- Medication review and management
- Coordination with specialists, pharmacies, labs, and hospitals
- Monthly phone check-ins
- 24/7 access to a healthcare professional for urgent needs
Chronic Care Management improves access to care, reduces gaps between appointments, supports medication safety, and helps patients stay on track with treatment plans — especially for complex or ongoing health needs.
Patients enrolled in CCM receive monthly check-ins, typically by phone, to review symptoms, medications, and care plans. Additional outreach may occur if health needs change.
Yes. CCM includes medication management to help prevent interactions, duplications, or missed prescriptions. It also supports coordination for services such as rehabilitation, outpatient IV therapy, and ongoing treatments.
You can enroll by speaking with your primary care provider or contacting Hereford Regional Medical Center directly at 806-349-9121. Enrollment requires patient consent and Medicare eligibility.
For more information or to enroll, contact:
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Cynthia Martinez, CCM Coordinator
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Phone: 806-349-9121
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Email: cynthia.martinez@dschd.org
People Matter
At Hereford Regional Medical Center, you can see for yourself how our team approaches care for our patients as though they’re our friends and family. After all, patients here are also our neighbors.
See how our team works together to ensure high-quality care for our community.
