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Chronic Conditions

Chronic Care Management is a service for patients with two or more chronic conditions. Research has proven that Americans with increased access and coordination get better care with more results at a lower cost.

What does CCM include?

A set of services geared toward your particular health needs and preferred mode of communication.

  • Access to your own personal Care Manager anytime and all the time you need it. Your Care Manager is intimately familiar with your individual care needs, and dedicated solely to you and a limited number of other Care Management members.
  • An individualized care plan available electronically for you to access and/or share 24 hours a day, 7 days a week.
  • At least 20 minutes per month of care plan review and progress update for chronic conditions such as diabetes, hypertension, heart disease, etc.
  • Coordination of care, meaning we make a point to communicate with other healthcare professionals in your life, and we incorporate their actions to our plans.

What insurances cover CCM?


What is my part?

  • Checkups: Monthly phone or electronic communication checkups are scheduled and required.
  • Compliance: When you and your Care Manager agree on a plan, follow it.
  • Courtesy: Feel free to address your urgent needs in an urgent manner, but please don’t abuse the service.
  • Communication: Contact your Care Manager about any healthcare you receive so that we can coordinate this in your plan.

Care Managers 

Your care managers are the very nurses who take care of you when you see the physicians at Shiloh Clinic. You will be assigned a compassionate nurse who knows your history. Each of our nurses is an expert at coordinating care on your behalf. They have extensive knowledge of the medical community and what services are available to improve your health. You will have 24-hour access who exhibit caring and competence. They have many years of combined clinical experience, which allows them to bring you a high level of care. The Shiloh nurses are excited about this opportunity to serve you better and develop a one-on-one relationship through our Chronic Care Management program. We feel that this will allow us to become your true partner in healthcare.

Team Approach

Shiloh Clinic embraces the team approach to patient healthcare. We gave a lot of consideration to the composition and function of our care teams. Our nurses, as team members, take more ownership and initiative and demonstrate increased camaraderie and mutual respect, resulting in better communications with our patients. High-performing clinical teams organized to provide proactive care are a tremendous resource in managing chronic diseases.

Team Meeting

Our physicians and nurses meet weekly to discuss the best ways to improve chronic disease management. This reinforces the Shiloh vision that your chronic medical conditions are a high priority for us and deserve our focused attention.