Chronic Care Management (CCM)

At Animo Sano Psychiatry, we understand the importance of comprehensive care for managing chronic conditions. Our Chronic Care Management (CCM) service offers personalized, coordinated support to enhance your overall well-being. With a focus on continuous care, we help you achieve better health outcomes and long-term stability

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What is Chronic Care Management (CCM)?

Chronic Care Management (CCM) offers specialized support for patients managing not just psychiatric conditions, but also any co-occurring physical health concerns expected to last at least 12 months. CCM is a proactive approach to care that involves ongoing communication, medication management, and seamless collaboration between all your healthcare providers for better health outcomes.

How Does CCM Work at Our Practice?

Our Certified Medical Assistants (CMAs) partner with clinical providers to deliver structured care between appointments, including:

  • Coordinating care with specialists
  • Managing medications and adherence
  • Addressing behavioral health needs
  • Assisting with referrals
  • Educate on conditions, medications, and coping strategies
  • Offering regular patient support

Who is Eligible for CCM?

CCM is designed for patients who are navigating the complexities of two or more chronic health conditions requiring ongoing care coordination. To ensure you can access this valuable service, your insurance plan needs to cover the Chronic Care Management Model. We encourage you to reach out to our team to discuss your specific situation and insurance coverage.

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Examples of Chronic Conditions Include, but are not limited to:

Behavioral Health Conditions

  • Major Depressive Disorder (MDD)
  • Generalized Anxiety Disorder (GAD)
  • Bipolar Disorder
  • ADHD
  • PTSD
  • Schizophrenia
  • Use Disorders
  • Chronic Insomnia
  • Alcohol abuse
  • Alzheimer’s disease and related dementia
  • Schizophrenia and other psychotic disorders 
  • Autism spectrum disorders 

Physical Health Conditions

  • Arthritis (osteoarthritis and rheumatoid)
  • Asthma
  • Cancer (breast, colorectal, lung, and prostate)
  • Chronic kidney disease
  • Chronic obstructive pulmonary disease (COPD)
  • Diabetes
  • Cardiac Conditions 
  • Hepatitis (chronic viral B & C) 
  • HIV and AIDS
  • Hyperlipidemia (high cholesterol)
  • Hypertension (high blood pressure)
  • Stroke

Key Coverage Considerations

  • Insurance coverage for Chronic Care Management (CCM) varies based on individual plans.
  • Medicare, Medicaid, and most commercial insurance providers cover CCM services when eligibility criteria are met.
  • No Additional In-Person Visits Required: CCM is a telehealth/remote service for convenient care coordination.
  • Monthly Billing: Billed monthly for ongoing care management.

Meet Our CCM Care Coordinator

Amanda Shore

Amanda Shore, CMA

Amanda Shore is a Certified Medical Assistant with over a decade of experience. She has honed her skills in primary care settings and dedicated herself to serving uninsured patients, offering both medical and mental health support. Through her work, she has cultivated a deep passion for helping individuals manage chronic conditions by meeting them where they are—physically, emotionally, and mentally.
She empowers patients through Chronic Care Management, combining compassion and personalized care to improve their health and quality of life.

How CCM Makes a Difference

Chronic Care Management (CCM) provides essential ongoing monitoring and personalized support for chronic psychiatric conditions, ensuring consistent follow-up, medication oversight and proactive interventions to improve well-being.

How to Get Started

If you are managing multiple chronic health conditions and believe you could benefit from enhanced support and coordination between your appointments, you may qualify for our Chronic Care Management (CCM) service. Contact our team today to learn more about how CCM can help you optimize your care.

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Frequently Asked Questions

Have questions? We have answers. Browse through our FAQ section to learn more about our psychiatry and behavioral health services, your first visit, and what to expect.

Chronic Care Management is a proactive, coordinated service designed for patients dealing with long-term health conditions (both behavioral and physical). Our CCM program offers continuous support between regular visits through medication management, education, referrals, and seamless coordination across your care providers.

To qualify for CCM, you typically need to have two or more chronic conditions expected to last at least 12 months. These can include behavioral health diagnoses like depression, anxiety, bipolar disorder, ADHD, OCD, PTSD, or physical conditions like diabetes, hypertension, COPD, arthritis, and more.

Our CCM services may include:

  • Coordinating care with specialists and other providers
  • Monitoring medications and helping with adherence
  • Addressing behavioral health needs
  • Educating you about your conditions, medications, and strategies for self-management
  • Assisting with referrals and follow-ups
  • Offering regular check-ins and support between clinical appointments

You need to be an Animo Sano Psychiatry patient and have qualifying chronic conditions to enroll. Our team will review your insurance for CCM coverage and help you complete the enrollment. Once accepted, you’ll receive coordinated care support tailored to your needs.

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