Chronic Care Management (CCM)

Your partner in managing chronic conditions—every day.

Metro Medical Associates is proud to offer Chronic Care Management (CCM) services designed to support patients living with long-term health conditions. Our team works proactively to manage your health between office visits, helping you achieve better outcomes and stay connected to care.

What Is CCM?

Chronic Care Management is a coordinated, proactive care model for people with two or more chronic conditions, such as diabetes, hypertension, COPD, heart disease, or arthritis. It includes regular check-ins, medication reviews, care coordination, and education to help you navigate your health journey.

Why Choose CCM at Metro Medical?

You’ll have at least one check-in per month (phone or secure portal) to review your symptoms, vital signs, and overall well-being.

Our care team—including nurse coordinators and pharmacists—reviews all your medications for safety, effectiveness, and ease, making adjustments as needed.

We collaborate with all providers involved in your care—from specialists to therapists—to ensure everyone is aligned on your treatment plan.

We empower you with resources and coaching to help manage your conditions, make healthy lifestyle changes, and understand warning signs.

Following discharge from the hospital or after specialist visits, we conduct follow-up care to manage your recovery and prevent hospital readmissions.

Who Benefits from CCM?

This program is ideal for patients with multiple or complex chronic diseases who encounter frequent medication updates or doctor visits, and those who could benefit from regular guidance and coordination.

How CCM Works at Metro Medical

  1. Enrollment & Care Plan Development
     We start by identifying eligible patients and creating a personalized care plan together, covering goals, medications, monitoring, and self-care steps.

  2. Monthly Check‑Ins & Monitoring
     Each month, you’ll have structured contact with our care team to assess status, address concerns, and update your care plan.

  3. Medication Reviews
     Our pharmacist or RN conducts comprehensive medication evaluations to align your treatment with clinical guidelines and your lifestyle.

  4. Coordination of Services
     We manage referrals, send updates to specialists, and arrange needed services like labs, imaging, nutrition, or behavioral health support.

  5. Patient Engagement & Education
     Through discussions and patient-friendly materials, we help you take charge of your health, empowering you to adhere to treatments and recognize changes early.

Benefits of CCM

  • Improved health outcomes: Evidence shows CCM supports better disease control, reduced hospitalizations, and increased patient satisfaction.
  • Reduced emergency visits: Proactive management helps avoid unnecessary ER visits and hospital stays.
  • Cost-effective care: Better-coordinated care is linked to lower overall costs and enhanced value.
  • Greater patient empowerment: Ongoing coaching builds confidence in managing your health effectively.

Meet Your CCM Team

Our CCM services are led by board-certified physicians Dr. Pavan Mamilla, Dr. Swetha Addagatla, and Dr. Ravali Kadari, supported by highly trained RNs, care coordinators, pharmacists, and behavioral health consultants.

How to Enroll

 

Step What You’ll Do
Discuss with Your Provider Ask your primary care doctor if CCM is right for you
Get Enrolled Provide consent, and we’ll set up your personalized care plan
Monthly Check‑Ins Expect a scheduled monthly touchpoint with your care team
Care Coordination We’ll keep everyone on your care team in sync
Ongoing Support You get education, reminders, and access whenever needed

Is CCM Right for You?

If you’re living with multiple chronic health conditions and want structured, comprehensive support—Chronic Care Management at Metro Medical Associates can put you at the center of your care, helping you live healthier and with greater peace of mind.

Ready to Join Our Care Family?

Ready to get started?

Talk to your provider during your next visit or contact our office to ask about enrolling in CCM.