Ongoing Support For Complex Health Needs, At Home
At Headwaters, we understand that managing chronic health conditions can be overwhelming—for both patients and their families. Our Chronic Care Management (CCM) program is designed to provide consistent, personalized support for individuals living with multiple ongoing medical conditions. Through regular check-ins, coordinated care planning, and easy access to our team, we help ensure patients receive the attention they need to stay healthier and more stable at home.
What Is Chronic Care Management?
Chronic Care Management is a Medicare-supported program for patients with two or more chronic conditions expected to last at least 12 months. The goal is to help patients better manage their health, reduce avoidable hospitalizations, and maintain the highest possible quality of life.
Conditions commonly included in CCM, but not limited to:
- Alzheimer’s disease and related dementias
- Heart disease
- COPD (Chronic Obstructive Pulmonary Disease)
- Diabetes
- Depression or anxiety
- Hypertension
- Arthritis
- Chronic kidney disease
- Cancer
- Asthma
- Atrial fibrillation
Our clinical team monitors each patient’s condition through scheduled phone calls and in-person visits as needed, offering continuity, peace of mind, and early intervention when issues arise.
Comprehensive, Personalized Care Plans
Every patient enrolled in our Chronic Care Management program receives a customized care plan, built around their goals, preferences, and clinical needs. These plans typically include:
- Identification of health concerns and risks
- Expected outcomes and prognosis
- Symptom and medication management strategies
- Home safety and support assessments
- Scheduled care coordination with specialists, pharmacists, and caregivers
Care plans are reviewed and revised regularly to reflect any changes in the patient’s condition or personal circumstances.
Communication & 24/7 Access
While most CCM support occurs during business hours, our team is available by phone 24/7 to respond to urgent concerns. Patients and caregivers also have access to secure communication methods—including phone, email, and electronic messaging—to ask questions, request follow-ups, or update the care team on health changes.
We prioritize responsiveness, helping our patients feel supported even between visits.
Transitional Care Management
When a patient experiences a change in care setting—such as returning home after a hospital or rehab stay—our Transitional Care Management (TCM) services help bridge the gap. We coordinate closely with hospitals, nursing facilities, and other providers to ensure medications, follow-up appointments, and care instructions are clearly understood and acted upon.
This reduces the risk of complications and supports a smoother recovery.
Is Chronic Care Management Right For You Or A Loved One?
If you or someone you care for lives with multiple ongoing health conditions and could benefit from coordinated, compassionate oversight, Headwaters is here to help. Call us today at 406-422-0114 to learn more.
Veteran-owned & locally operated | Serving Helena, Butte, and surrounding Montana communities
