title: Chronic care coordination.
abstract: Chronic care management describes the services provided to patients with two or more chronic conditions that pose risks of exacerbation, clinical deterioration, or death. These services extend beyond the typical face-to-face office visit and require coordination and oversight by a physician or other qualified health-care professional to maintain and modify as necessary a comprehensive and multidisciplinary plan of care. New codes for 2015 describe chronic care management services per calendar month. While the new services acknowledge the role and importance of coordination by primary care providers, they are also appropriate for specialists who oversee the management of all of the chronic conditions of a patient and provide access, education, care coordination, communication, and health information exchange with other providers.
authors.affiliation: Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Mayo Foundation for Medical Education and Research, Rochester, MN. Electronic address: Peters.Steve@Mayo.edu.
authors.forename: Steve G
authors.initials: SG
authors.lastname: Peters
authors.affiliation: Department of Family Medicine, Mayo Clinic Health System, Owatonna, MN.
authors.forename: Kari S
authors.initials: KS
authors.lastname: Bunkers
mesh_terms: D002908:Chronic Disease / Q000628:therapy*; D003695:Delivery of Health Care / Q000458:organization & administration*; D006801:Humans; D008134:Long-Term Care / Q000458:organization & administration*