Care Management (CM): Expert, Team-Based Support

Our clinical pharmacists and registered nurses collaborate closely with your primary care provider to help you manage medications, coordinate care, and improve your overall health. Pharmacists focus on optimizing treatment plans to ensure they are safe and effective, while nurses provide education, care planning, and follow-up support. 

This collaborative approach is supported through Provider-Delivered Care Management (PDCM) in Michigan and is designed to improve outcomes, reduce hospital visits, and simplify health management.

Chronic Care Management (CCM): Ongoing Support for Long-Term Conditions

If you have two or more chronic conditions and are covered by traditional Medicare, you may qualify for our Chronic Care Management program. Our CCM team – including skilled Medical Assistants – offers monthly check-ins, personalized outreach, and care coordination between visits. This service helps patients with conditions like diabetes, hypertension, or COPD stay on track, avoid unnecessary hospitalizations, and feel more confident in managing their health.

Remote Patient Monitoring (RPM): Care from the Comfort of Home

With RPM, we can track important health information such as blood pressure, blood sugar, or weight right from your home. Our team reviews this data in real time and can step in quickly if changes are needed, keeping you safe, supported, and empowered between visits.

Whole-Person Care Approach

Our care team works in collaboration and continuous partnership with patients, families, caregivers, specialists, and community resources. Together, we aim to:

• Promote timely access to appropriate care
• Increase preventive care services
• Reduce emergency room visits and hospital readmissions
• Improve understanding through culturally and linguistically appropriate education
• Create and support adherence to individualized care plans
• Improve continuity of care across providers and care transitions
• Provide medication reconciliation and optimization
• Connect patients with community resources
• Support advance directives, palliative care, hospice, and end-of-life planning
• Encourage self-management and shared decision-making

Michigan Primary Care Partners proudly participates in Blue Cross Blue Shield of Michigan’s Provider Delivered Care Management (PDCM) program. We also provide care management services for patients with other participating health plans under an all-patient, all-payer model of care.

Contact our clinic today to learn more and enroll in these additional services.