We believe one size does not fit all when it comes to caring for people living with chronic medical conditions. Instead, it should be personalized. We know this is accomplished when the primary care doctor is leading care and has the clinical support and resources to deliver the care that fits all of a patient’s physical, mental, emotional, social, and spiritual health needs.
That’s why CCP established a centralized clinical services team — to support our CCP practices, provide enhanced services, and extend your care team beyond the four walls of your doctor’s office. These services are geared toward our aging patients with multiple chronic health conditions. The goal is to provide extra support and services so these patients don’t end up in the emergency room – which can be scary and costly for patients and caregivers. As one care team, our clinicians work with your providers to identify issues early on, provide the right resources at the right time, and work to keep you well.
CCP’s central clinical services team includes physicians, nurse practitioners, physician assistants, pharmacists, behavioral health consultants, nurses, and support staff from Community Care Physicians and our partners at Honest Medical Group. We are an extension of your doctor’s office, and we are focused on supporting you with customized programs and resources, including:
- Care management teams to help coordinate complicated and unique care
- Home visits to get focused care in the comfort of your home
- Clinical support teams who are passionate about taking care of the whole patient
- Real-time feedback into medical conditions so your doctor can better address your needs
Our services are all coordinated by your CCP physician, and they are available free of charge to eligible patients.
The Roles of Our Team in Your Care
Advanced Practice Providers
Our team of clinical pharmacists, nurse practitioners and physician assistants support our initiative to broaden access to Medicare Wellness visits to patients remotely and telephonically. Our clinicians conduct visits with Medicare patients to identify appropriate preventative health screenings and immunization opportunities.
Registered Nurse Care Managers
Registered Nurse Care Managers (RN CMs) provide ongoing support to patients to assist them in reaching their healthcare goals while collaborating closely with your primary care provider. Whether it be support upon discharge from the hospital to prevent future hospitalizations or comprehensive disease state management, the RN Care Managers are an integral part of the patient’s care team.
Patient Support Representatives
Patient Support Representatives (PSR) provide clerical support to clinical staff from across the Clinical Services Department. The Clinical Services PSRs assist with scheduling appointments for central Medicare wellness visits in addition to appointments with CCP Weight Management.
Pharmacy Care Coordinators
Pharmacy Care Coordinators at CCP provide daily support to our team of Clinical Pharmacists. Pharmacy Care Coordinators routinely contact insurance companies to verify eligibility & coverage and contact patients to ensure they are taking routine medications as prescribed. Pharmacy Care Coordinators also assist patients in applying for various patient assistance programs to help with the cost of their prescription medications.
Care Management Care Coordinators
The team of Care Management Care Coordinators at CCP provides daily clerical support to the RN Care Managers. In addition, they help patients get connected with a variety of resources from throughout the community, ensure appropriate medical records from outside providers and hospitals are obtained by your primary care providers in a timely fashion, and help patients get necessary appointments scheduled.
Prior Authorization Coordinators
The team of prior authorization coordinators provides support to CCP Practices in obtaining insurance prior authorizations for prescription medications. Prior Authorization Coordinators frequently contact patients and pharmacies to obtain updated insurance information and will contact patients to let them know the status of their authorization request.
Honest Transition of Care Coordinators
Transition of Care Coordinators at CCP provide support to patients from hospital admission to discharge. The transition of care coordinator keeps our integrated care team and primary care providers up to date about our patient’s hospital course in real-time and ensures that they have all they need to seamlessly transition upon discharge.
Licensed Medical Social Workers
Licensed Medical Social Workers (LMSW) provide nonclinical social support to meet individuals’ and families’ needs. Our LMSWs work closely with the integrated care team to connect patients with the supports they need to address social determinants of health and create individual support plans ensuring our patients have the tools needed to optimize their health and navigate the healthcare system.
View Frequently Asked Questions
These services are available at no cost to you. To view other frequently asked questions about eligibility and services, check out our frequently asked questions.