Chronic Care Management Program (CCM)

Chronic Care Management Program (CCM)

Chronic Care Management Program (CCM)

Chronic Care Management (CCM) is a Medicare program that helps you stay on top of your health between visits. If you live with two or more ongoing health conditions, CCM gives you extra support from our care team, even when you are not in the clinic.

How CCM Helps You

When you enroll in Chronic Care Management (CCM) you will have a dedicated Care Coordinator who checks in with you each month. These touchpoints help us track your progress, answer questions, and coordinate care with other providers or specialists you may see.

CCM benefits include:

  • A personalized Comprehensive Care Plan
  • Monthly check-ins with your Care Coordinator
  • Help managing medications
  • Support with referrals and care coordination
  • Better communication with your Clinica Sierra Vista care team

Program Requirements

Medicare requires that you:

  • Have two or more chronic conditions (we will let you know if you qualify)
  • Give consent for Clinica Sierra Vista to provide Chronic Care Management (CCM) services
  • Allow secure electronic sharing of your health information with other treating providers when needed for your care
  • Understand that only one provider organization can bill Medicare for CCM in a calendar month
  • Understand that CCM is a cost-share program under Medicare. Medicare covers most of the cost, and any remaining balance may be billed to you if it is not covered by a secondary plan or Medicare Advantage plan.

CCM services are provided through telephone support with your Care Coordinator, who works closely with your Clinica Sierra Vista provider.

Enrollment

If you choose to enroll, a Care Coordinator will contact you each month. Our CCM team includes Registered Nurses, Licensed Practical Nurses, and trained Medical Assistants who support your care based on your provider’s plan.

Questions?

Call us at (661) 404-1139.
To learn more about Medicare’s Chronic Care Management program, visit www.cms.gov ↗.

Program Objectives

  • At least 80% of interns complete program/degree requirements within 13.5 months (150% of planned program length).
  • Of graduates who seek employment, at least 100% are employed in nutrition and dietetics or related fields within 12 months of graduation.
  • At least 80% of program graduates take the CDR credentialing exam for dietitian nutritionists within 12 months of program completion.
  • The program’s one-year pass rate (graduates who pass the registration exam within one year of first attempt) on the CDR credentialing exam for dietitian nutritionists is at least 80%.
  • 80% of employers, who return surveys, rate graduates as “satisfactory” or “excellent” for ability to work effectively with multicultural populations from diverse backgrounds.
  • 90% of program graduates work as entry-level Registered Dietitian Nutritionists in community nutrition.
  • 90% of graduates work in Central Valley community programs for at least two years after graduation.

Do I Qualify for WIC?

WIC is a program that helps families with food and nutrition. Call us at (661) 862-5422 or send a message, and we’ll help you see if you qualify.

Here are some ways you might qualify:

  • You are pregnant
  • You are breastfeeding a baby who is less than one year old
  • You had a baby in the last six months
  • You have a child who is under the age of five
  • You experienced a loss of pregnancy or had a termination

You also need to think about your family’s income. Here are the monthly income limits for family sizes:

  • 1 Person: $2,413
  • 2 Persons: $3,261
  • 3 Persons: $4,109
  • 4 Persons: $4,957
  • 5 Persons: $5,805
  • More than 5 Persons: Add $848 for each additional member

This income limit is based on 185% of the Federal Poverty Level, and these amounts will be effective from April 1, 2025, to June 30, 2026.

Also, if you’re pregnant, the baby counts as part of your family size when figuring out if you qualify.

Get Care Right Away

Need care right away? Our health centers offer same-day appointments, and our walk-in clinics also offer extended hours. Whether you schedule ahead or stop by, we’re here to deliver fast, high-quality care when and where you need it.

Visit Your Preferred Location

We make it easy to choose the clinic that works best for you. Keep in mind that your preferred location may mean seeing a different provider. Either way, you’ll receive compassionate, expert care from our trusted team, no matter which clinic you visit.

See Your Preferred Provider

Our providers work across multiple clinics to make care accessible, so their location may vary based on availability. No matter where you’re seen, you can trust our dedicated team to deliver the high-quality care you deserve.