Dedicated to caring for our community since 1967

Chronic Care Management (CCM)

Together, we are a team. 


Our Chronic Care Management (CCM) model involves services provided by a care team - including a Care Coordinator, Physician, Nurse Practitioner (NP), Physician Assistant (PA), Certified Nurse-Midwife (CNM), or Clinical Nurse Specialist (CNS) - and their clinical staff. The team provides support to patients with chronic conditions, coordinates the patients’ physical and behavioral healthcare services, and connects them to community services and housing, as needed. The care coordinator may check-in weekly, biweekly, or monthly over-the-phone, and/or in-person with patients. 

The Centers for Medicare and Medicaid Services (CMS) identifies 27 conditions that are considered reimbursable for outreach work provided to patients. To qualify, patients must have at least two of the following conditions: 

1. Acquired Hypothyroidism 

2. Acute Myocardial Infarction 

3. Alzheimer’s Disease 

4. Alzheimer’s Disease and Related Disorders or Senile Dementia 

5. Anemia 

6. Asthma 

7. Atrial Fibrillation 

8. Benign Prostatic Hyperplasia 

9. Cataract 

10. Chronic Obstructive Pulmonary Disease and Bronchiectasis 

11. Chronic Kidney Disease 

12. Colorectal Cancer 

13. Depression 

14. Diabetes 

15. Endometrial Cancer 

16. Female/Male Breast Cancer 

17. Glaucoma 

18. Heart Failure 

19. Hip/Pelvic Fracture 

20. Hyperlipidemia 

21. Hypertension 

22. Ischemic Heart Disease 

23. Lung Cancer 

24. Osteoporosis 

25. Prostate Cancer 

26. Rheumatoid Arthritis/Osteoarthritis 

27. Stroke/Transient Ischemic Attack 

CCM services are provided apart from, and in addition to, in-person visits, and services are centered on attributes of advanced primary care. The program offers extra services to members with complex medical needs and chronic conditions. This includes providing the patient an ongoing relationship with a designated clinician, offering 24/7 access to health information and patient care, giving support to patients with chronic diseases as they work to achieve health goals, sharing and utilizing health information in a timely fashion, and engaging patients and their caregivers in their care plan. With CCM, patients are equipped to be an active participant in the management of their health and treatment. Patients receive education, psychosocial support, training in necessary skills, and cooperation between patients and their providers as part of their self-management support. 

The services involved in CCM are extensive and include: maintaining comprehensive care management, completing electronic care plan, performing care coordination, transitions of care along with other care management services, recording structured patient health information, and timely communication of patient health information, providing health promotion and services to help members with community and social services, such as housing, transportation, and food. 

Patients must consent to be enrolled in the CCM program. If you believe that you have two or more of the chronic diseases listed above, and you would like to participate in the program, please contact:

The Quality Department


Phone: (323) 234-5000 ext. 133

Meet our CCM Team today!

The CNHF Chronic Care Management project is funded in part by L.A. Care Health Plan and will benefit low-income and uninsured residents of Los Angeles County.

Federal Tort Claims Act
NCQA Recognized Practice