Chronic Care Management (CCM)

A proactive and collaborative approach to improving clinical care outcomes

Patients with multiple chronic conditions need active, ongoing oversight, not static plans. Lumina Care’s Chronic Care Management (CCM) program delivers continuous follow-up, managed escalations, and robust monthly care planning.

Chronic Care Management (CCM)

A proactive and collaborative approach to improving clinical care outcomes

Patients with multiple chronic conditions need active, ongoing oversight, not static plans. Lumina Care’s Chronic Care Management (CCM) program delivers continuous follow-up, managed escalations, and robust monthly care planning.

Chronic Care Management (CCM)

A proactive and collaborative approach to improving clinical care outcomes

Patients with multiple chronic conditions need active, ongoing oversight, not static plans. Lumina Care’s Chronic Care Management (CCM) program delivers continuous follow-up, managed escalations, and robust monthly care planning.

Our approach expands your team’s ability to stay ahead of complications without adding extra work.

~5%

~5%

Reduction in rehospitalizations with CCM

Reduction in rehospitalizations with CCM

(CMS)

$

$

CCM lowers Medicare spend over time

CCM lowers Medicare spend over time

(CMS)

A clinical program that continually moves care forward

Lumina Care’s CCM program is structured and evidence-based. We prioritize high-risk patients and analyze their complete medical picture. Our active communication approach ensures that everyone on your care team knows what’s required and when.

Lumina Care provides the clinical resources providers need to manage complex, chronic care

Clinical teams are starting each day short on the time they need to truly meet the needs of their patients. It’s inevitable that when opportunities are missed, escalations and readmissions become part of the status quo.

While we’re seeing clinicians, administrators, and specialists doing their best every day, CMS expectations of value-based care are expanding.

Behavioral Health Integration is commonly provided alongside CCM to improve access to behavioral health resources.

70%

Medicare beneficiaries with two or more chronic conditions

Capabilities

Chronic Care Management by Lumina Care

Patient care

  • Patient identification and prioritization based on chronic illness burden

  • Complete review of each patient’s history, diagnoses, and medications

  • Initial Patient Visit (IVP) completed by a Lumina Care provider 

  • Monthly check-ins review progress and update plans

  • Support with medication management and gradual dose reductions (GDRs)

  • Therapy and dietary recommendations tailored to the patient

  • Personalized chronic care plans use evidence‑based guidelines

Clinical collaboration and operations

  • Care plans and documentation are communicated to your clinical team 

  • Daily updates in Lumina360 show opportunities to improve care

  • Care opportunities escalated to clinical leadership

  • Ongoing communication with your onsite clinicians and administrators

  • Workflows built to follow CMS requirements and fit into your operations

Capabilities

Chronic Care Management by Lumina Care

Patient care

  • Patient identification and prioritization based on chronic illness burden

  • Complete review of each patient’s history, diagnoses, and medications

  • Initial Patient Visit (IVP) completed by a Lumina Care provider 

  • Monthly check-ins review progress and update plans

  • Support with medication management and gradual dose reductions (GDRs)

  • Therapy and dietary recommendations tailored to the patient

  • Personalized chronic care plans use evidence‑based guidelines

Clinical collaboration and operations

  • Care plans and documentation are communicated to your clinical team 

  • Daily updates in Lumina360 show opportunities to improve care

  • Care opportunities escalated to clinical leadership

  • Ongoing communication with your onsite clinicians and administrators

  • Workflows built to follow CMS requirements and fit into your operations

A partner that expands your team’s ability to manage complex care

Our CCM program is more than a check-in service—it’s an integrated, clinically led extension of your care team. We coordinate directly with your onsite clinicians, administrators, and PCPs to ensure care plans evolve, opportunities are identified, and chronic conditions are actively managed or improved.

A partner that expands your team’s ability to manage complex care

Our CCM program is more than a check-in service—it’s an integrated, clinically led extension of your care team. We coordinate directly with your onsite clinicians, administrators, and PCPs to ensure care plans evolve, opportunities are identified, and chronic conditions are actively managed or improved.

A partner that expands your team’s ability to manage complex care

Our CCM program is more than a check-in service—it’s an integrated, clinically led extension of your care team. We coordinate directly with your onsite clinicians, administrators, and PCPs to ensure care plans evolve, opportunities are identified, and chronic conditions are actively managed or improved.

Talk to an expert

Connect with Lumina Care and learn how we enhance your team’s capabilities, improve care outcomes, and relieve the burden on your staff.

Talk to an expert

Connect with Lumina Care and learn how we enhance your team’s capabilities, improve care outcomes, and relieve the burden on your staff.

Talk to an expert

Connect with Lumina Care and learn how we enhance your team’s capabilities, improve care outcomes, and relieve the burden on your staff.

Stay connected

Sign up for news, announcements, and exclusive insights

Stay connected

Sign up for news, announcements, and exclusive insights

Stay connected

Sign up for news, announcements, and exclusive insights