Chronic Care Management

Pinehurst Medical Clinic offers comprehensive chronic care management services to Medicare patients with two or more chronic conditions, who would benefit from having a dedicated nurse care manager. Our nurse care managers work closely and diligently with the patient's Pinehurst Medical Clinic primary care provider. This ensures seamless and convenient communication is occurring on behalf of the patient.

Nurse care managers provide the following to chronic care management patients:

  • Offers support and coaching over the phone to assist with health-related concerns
  • Identifies and secures community resources that would benefit the patient
  • Keeps in regular contact with the patient to ensure care plans and goals are exceeded
  • Assists with medication management
  • Serves as a liaison between patients and their healthcare teams
  • Provides resources to help navigate the decision-making process

In addition to chronic care management, Pinehurst Medical Clinic offers transitional care management to those patients needing assistance with the lifestyle changes after a hospitalization. This team works with patients up to 30 days after a hospital discharge to help patients with the following: 

  • Education on disease processes
  • Provide community resources and referrals
  • Assistance with medications
  • Collaboration with those involved in the patient's care journey 

By providing the above assistance, Pinehurst Medical Clinic Chronic Care Management and Transitional Care Management teams help to reduce the likelihood of readmission and emergency department visits. 

For more information about Pinehurst Medical Clinic's chronic care management and transitional care management programs, please talk to your provider or call 910-235-3367.

Chronic Care Management Team

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Chronic Care Management Conditions & Diseases

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Chronic Care Management Resources

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