Care Coordination & Chronic Care Management

Management of chronic medical conditions in Duluth

What is care coordination and chronic care management?

Care coordination is a team approach to health care that provides access to all the services and support you may need. Chronic care management is care coordination for Medicare and dual eligible (Medicare and Medicaid enrollees) patients. Most primary care clinics within the Aspirus St. Luke's health system are a certified health care home. They will work with you to coordinate and deliver care that focuses on your health care goals.

Who is eligible for care coordination and chronic care management services?

These services are recommended for patients with chronic or complex medical conditions. Examples of chronic or complex medical conditions include but are not limited to:

• Asthma
• Hypertension
• Arthritis
• Chronic pain
• Seizure disorders
• Diabetes
• Cardiovascular disorders
• Mental health disorders

All Aspirus St. Luke's patients are welcome to sign up for care coordination or chronic care management services. Speak with the care coordinator at your primary care clinic or your primary care provider to see if these services would be beneficial to you.

How can a care coordinator help me?

A care coordinator serves as a direct contact to help address any questions or concerns you may have about your health care. This care coordinator can also help you with the following:

• Connecting you to your primary care provider or medical assistant
• Helping you schedule appointments at health care facilities
• Assisting with the coordination of care between your primary care provider and other specialty care providers
• Supporting you in making informed health care decisions
• Referring you to useful community resources such as transportation, housing, financial and food support

Who is on my Health Care Home team?

Your Health Care Home team is the group of individuals who all have an active role in your health care. This group may include:

• You

• The care coordinator at your primary care clinic
• Your primary care provider
• Other health care providers (physical therapists, medical assistants, etc.)
• Your community support service providers
• Trusted family and friends

Are care coordination and chronic care management services covered by my insurance?

Many insurance companies recognize the benefits of care coordination and chronic care management and offer coverage for these services. Chronic care management, which is care coordination for Medicare and dual eligible patients (Medicare and Medicaid enrollees), is covered by most Medicare plans. For questions about coverage for care coordination and chronic care management services under your specific plan, please contact your insurance provider directly. The contact number for your insurance provider can be found on the back of your insurance card.

How do I sign up for care coordination or chronic care management?

Contact your primary care clinic and ask to speak with the care coordinator. You can also talk to your primary care provider and ask if these services would be beneficial to you.

I am already enrolled in care coordination or chronic care management services. What do I do if my primary care clinic is closed?

If you’re enrolled in these services, you have access to an after-hours phone line staffed from 4:30 p.m. to 8 a.m. when your primary care clinic is closed. For assistance, call 218.249.HOME (4663).

Additional Resources

What is a Health Care Home?: Find out more from the Minnesota Department of Health about the Health Care Homes (HCH) program.

Chronic Care Management: Information about chronic care management from the Centers of Medicare & Medicaid Services.

Centers for Medicare & Medicaid Services: Information on Medicare and Medicaid services including coordination, private insurance, regulations and more.

5 Ways to Make the Most of Your Health Coverage: Once you have health care coverage, these are five things you can do to put your health first.

A Roadmap to Better Care and a Healthier You: This road map explains what health coverage is and how to use it to get the health care you need.

Referral required for this service. If you need one, talk to your primary care provider.

To establish care with a Aspirus St. Luke's primary care provider, call 218.249.4000 or find a clinic near you.