Call us at 208-234-2300
110 Vista Drive, Pocatello, Idaho

Chronic Care Management

Program Overview

Nationwide, the Centers for Medicare & Medicaid Services (CMS) recognizes care management as one of the critical components of primary care that contributes to better health and care for individuals. Our care managers work with your medical providers to help our patients overcome barriers to achieving improved health by promoting patient self management. Patients receive targeted interventions with a focus on:

Consistent use of a medical home

  • Access to medical care
  • Adherence to prescribed medication and treatment plans
  • Identification of behaviors that impact a healthy lifestyle
  • Comorbid health problems

Practitioner Benefits

Our Chronic Care Management program helps your doctor to coordinate care for high risk, chronically ill patients by:

  • Conducting assessments while patients are in their home environments
  • Identifying barriers that impact health.
  • Coaching patients on understanding their conditions and adhering to treatment plans and lifestyle modifications.
  • Coordinating follow-up care with specialists or ancillary services.
  • Providing appointment reminders and help with transportation arrangements to ensure access to providers and decrease missed appointments.

Program Goals

Our Chronic Care Management Team works with practitioners in:

  • Educating their patients with individualized telephone calls.
  • Counseling and health education.
  • Providing feedback on patient-related issues.
  • Discussing your concerns with your primary care doctor and midlevel provider.
  • Improving health outcomes by sharing relevant evidence-based practice guideline information

Our Chronic Care Management Team works with patients to:

  • Help eligible patients better manage their chronic conditions.
  • Provide patients with scheduled calls, easy to understand written materials, and 24/7 access to your care team.
  • Reinforce and reminding you of details of your medical visit
  • Help coordinate follow-up appointments and services.
  • Assist with prescription compliance and renewals.

Patient Eligibility & Identification

Our Chronic Care Management Program is a service provided to eligible patients.  Eligible patients are identified as patients with two or more chronic conditions. A comprehensive care plan is established, implemented, revised, and monitored.

Chronic Condition Support

Our Chronic Care Management Program promotes adherence to the primary care practitioner’s treatment plans for patients who have chronic conditions, some of which are:

  • Alzheimer’s disease and related dementia
  • Arthritis
  • Asthma
  • Atrial fibrillation
  • Autism spectrum disorders
  • Bipolar Disorder
  • Cancer
  • Chronic Obstructive Pulmonary Disease
  • Coronary Artery Disease
  • Depression
  • Diabetes
  • Heart Failure
  • High Blood Pressure
  • High Cholesterol
  • Ischemic heart disease
  • Thyroid Disease
  • Obesity
  • Osteoporosis

Clinical Guidelines

Our Chronic Care Management Program is designed using current, nationally recognized evidence-based clinical guidelines.

Chronic Care Management Program

Chronic Care Management Program works with patients to improve their health and quality of life. Our program consists of case management, care coordination and preventive health education, including chronic disease self-management.

The Chronic Care Management Program is delivered by a team of certified medical assistants, licensed practical nurses, registered nurses and other professional staff to provide knowledge, support, and monitoring for patients between practitioner visits.

How to Contact Us:

1. Patient Portal
Go to our website:
Log onto the Patient Portal and send a message directly to your CCM Nurse!

2. Urgent Calls ONLY (after 8 pm)
(208) 241-2390


Chronic Care Managers are not a substitute for emergency care. If you’ve suffered a serious or life-threatening injury, call 911 or go to an emergency room immediately.

The Primary Care Specialists Chronic Care Management Program is a care management program designed to help patients with chronic medical conditions to improve and better manage their health.