What is Chronic Care Management (CCM) and How It Helps Our Patients

For many of our patients living with chronic conditions like diabetes, heart disease, COPD, or hypertension, a single monthly NP visit is incredibly valuable — but it's not always enough. That's where our Chronic Care Management (CCM) program makes a meaningful difference.

How CCM works at Kings County House Calls

Between your regular Nurse Practitioner home visits, one of our trained CCM Care Coordinators reaches out to you (or your caregiver) for a monthly wellness check. These calls focus on how you're truly doing at home and help connect the dots between visits.

During these check-ins, your CCM coordinator can:

• Review how you're feeling and catch any new or worsening symptoms early
• Help with medication refills and ensure you're not running low
• Coordinate referrals to specialists or additional services
• Assist with medical forms, insurance questions, or transportation needs
• Answer questions and provide peace of mind between visits

Why patients and families love CCM

Many caregivers tell us the monthly CCM call is one of the most helpful parts of our service. It closes the gap between visits, reduces stress, and helps prevent small issues from becoming big problems. Everything is coordinated with your NP so care remains seamless.

Who can benefit?

CCM is available to most of our patients managing ongoing health conditions. There is no additional cost for eligible Medicare patients — it is covered by Medicare as a valuable preventive service.

If you're already a patient and haven't been enrolled in CCM yet, simply ask your NP or call our office at 718-444-7766. We'll be happy to get you started.