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.
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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.
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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
Other Services
Comprehensive clinical evaluations, medication management, diagnostic orders, and care coordination
— delivered by licensed medical providers in your home.
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Expert symptom management and comfort-focused care for patients living with serious illness — supporting patients and families with clinical precision and genuine compassion.
​Specialized psychiatric evaluation and ongoing mental health management — delivered by licensed providers trained to address depression, anxiety, and dementia-related behavioral conditions in the home setting.