Condition Management – Practitioner Services Jordan Plumbee
The Care Coordination Institute (CCI) is based in Greenville, South Carolina and is committed to partnering with physicians, hospitals and other healthcare providers to transform the health of communities through facilitation and education around coordination of care, evidence-based best practices and the promotion of healthy lifestyles. Our goal is to have a positive impact on quality, healthcare costs and the patient experience. The Condition Management program, a care coordination service offered through CCI, is available to eligible patients who are identified for diabetes, congestive heart failure, chronic obstructive pulmonary disease, asthma, hypertension and hyperlipidemia.
The program is designed to collaborate with practitioners and patients to identify opportunities for prevention and intervention to provide well-coordinated care. Patients enrolled in the condition management program will work with a health coach to develop a plan of care founded on evidence-based guidelines and interventions specific to their conditions or risks. Intervention plans are tailored based on screenings, immunizations, self-management education and support, medication adherence and goal-setting. The health coach will encourage adoption of healthy lifestyle behaviors and assist the patient with referrals to support groups and condition-specific programs including diabetes self- management, medical nutrition therapy, weight management, smoking cessation, and depression. The health coach will interact with patients through phone calls or in person meetings. Educational materials are given to support all self-care efforts of the patient.
As a practitioner, the health coach will provide you with the care plan for your patient, along with updates on the progress of your patient through their electronic medical record (EMR), via fax or postal services. Utilizing this service allows you to partner and communicate with your patient’s health coach to provide feedback or concerns regarding the well-being of your patient. Unscheduled communication between you and the health coach may occur if clinical questions arise concerning the patient’s medication or if there are immediate concerns about your patient’s safety.
Questions, concerns or complaints can be sent to firstname.lastname@example.org or call (844) 808-9347. Our hours of operation are Monday through Friday from 8-5 p.m.