Chronic Care Management
Structured Clinical Support for Long-Term Conditions.
Calora Health's Chronic Care Management program delivers consistent clinical oversight for patients managing complex, ongoing health conditions — between appointments, not just during them.
Chronic disease management requires more than periodic clinic visits. Meaningful outcomes depend on regular monitoring, proactive intervention, and a coordinated care infrastructure that keeps pace with the patient's evolving needs. Calora Health's CCM program closes the gap between appointments — providing structured, in-home clinical support that reduces complications, minimizes hospitalizations, and improves long-term health outcomes.
CCM Program Components
Convenient and professional medical care right where you live
Individualized
Care Plan
A comprehensive written care plan developed with the patient, caregivers, and existing care team — reviewed and updated as clinical needs evolve.
Lab & Diagnostic
Tracking
Coordination and follow-up on all ordered diagnostics — ensuring results are reviewed, acted upon, and communicated to appropriate providers.
Regular Clinical
Check-ins
Scheduled in-home visits and ongoing monitoring to assess status, identify early warning signs, and
adjust the care plan before conditions deteriorate.
Patient & Caregiver
Education
Condition-specific education delivered in the patient's home — supporting informed decision-making
and improved treatment adherence.
Medication
Management
Ongoing review and reconciliation of all medications — including refill coordination, dosage
adjustments, and adherence support.
Multi-Provider
Coordination
Active communication with the patient's full care team — including primary care, specialists, and pharmacy — to ensure alignment across all treatment objectives.
Conditions Supported
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Type 1 and Type 2 Diabetes
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Hypertension
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Congestive Heart Failure
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Chronic Obstructive Pulmonary Disease (COPD)
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Asthma
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Chronic Kidney Disease
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Obesity and Metabolic Syndrome
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Additional qualifying chronic conditions as defined by Medicare guidelines
What Our Patients & Families Say
Hear how compassionate, personalized care has made a difference for the people and families we serve.
Explore Our Other Services
Explore additional care options designed to meet the changing needs of our patients and families.
Professional medical evaluations, treatment support, and care coordination delivered in the comfort of home.
Compassionate symptom management and supportive care for children and families facing serious or complex conditions.
Skilled, one-on-one nursing care for adults with complex medical needs, delivered by licensed nurses at home.