Care Coordination

Chronic Care Management (CCM)

At CCMSD, our Care Coordination team is committed to helping patients manage their chronic conditions effectively through our Chronic Care Management (CCM) program. This program is specifically designed for patients living with two or more chronic conditions, such as diabetes, heart disease, COPD, arthritis, or hypertension.

Our team of healthcare professionals works closely with patients to develop personalized care plans tailored to their unique needs. Here's what you can expect from our CCM program:

Comprehensive Care Planning

We take the time to understand your health history, current challenges, and long-term goals. Together, we create a plan that focuses on improving your quality of life and preventing complications.

Regular Check-Ins

Through scheduled phone calls or virtual appointments, our care team stays in touch to monitor your progress, provide support, and answer any questions. This ongoing communication helps ensure you stay on track and receive the care you need.

Coordinated Care

Our care coordinators act as a bridge between you and your healthcare providers. We help schedule appointments, follow up on test results, and communicate with specialists to keep your care streamlined and effective, ensuring that you receive optimal care coordination and Care Coordination.

Our care coordinators act as a bridge between you and your healthcare providers. We help schedule appointments, follow up on test results, and communicate with specialists to keep your care streamlined and effective.

Medication Management

Managing multiple medications can be challenging. We review your prescriptions to ensure they are appropriate and effective, providing guidance to help you adhere to your treatment plan.

Preventive Focus

By addressing potential health issues early and supporting lifestyle changes, our goal is to reduce the risk of hospitalizations and emergency visits.

Benefits of CCM

• Improved Health Outcomes: Patients in CCM programs often experience better disease management and fewer complications.
• Reduced Stress: Knowing someone is keeping an eye on your care can provide peace of mind.
• Access to Resources: Our team connects you with the tools and resources you need to succeed.

If you or a loved one has two or more chronic conditions, you don’t have to navigate them alone. Let us help you take control of your health and achieve a better quality of life.

To learn more about our Chronic Care Management program or to enroll, please call us at 307-283-3970 or stop into the Hulett, Sundance, or Moorcroft clinics to learn more. 

Your health is our priority, every step of the way.

Behavioral Health Integration (BHI)

At CCMSD, we understand that mental health is a vital part of overall well-being. Our Behavioral Health Integration (BHI) program bridges the gap between mental and physical health, ensuring patients receive comprehensive care for both.

This innovative program combines the expertise of our behavioral health team with the support of your primary care provider to address your unique needs holistically.

What We Offer Through BHI Mental Health Screenings

Our program includes regular screenings to identify conditions such as depression, anxiety, PTSD, or other behavioral health concerns. Early detection allows us to intervene quickly and provide the support you need.

Personalized Treatment Plans

We collaborate with your primary care provider to develop a treatment plan that incorporates mental wellness into your overall care. This ensures your physical and mental health are treated as interconnected, not separate, aspects of your health.

Therapy and Counseling Coordination

We help connect you with qualified therapists, counselors, or psychiatrists as needed. Whether you require short-term counseling or ongoing therapy, our team ensures you have access to the right resources.

Medication Support

For patients requiring medication to manage mental health conditions, our care team coordinates with your providers to ensure medications are effective and monitored for optimal results.

Crisis Intervention and Support

In times of acute need, we are here to guide you through the challenges. Whether you are experiencing a mental health crisis or need urgent support, our team works to stabilize the situation and connect you with critical resources.

Education and Resources

We provide information on coping strategies, stress management, and lifestyle changes that can enhance mental health and overall well-being.

Why Choose BHI at CCMSD?

• Whole-Person Care: We believe your mental and physical health are equally important and work to integrate care seamlessly.
• Accessible Services: Our team works to remove barriers, making it easier to access mental health support.
• Coordinated Approach: We serve as a central point of contact for your care, ensuring nothing gets overlooked.
• Improved Outcomes: Patients receiving integrated care often report better quality of life, improved physical health, and enhanced emotional resilience.

How to Get Started

If you or someone you love could benefit from Behavioral Health Integration, we are here to help. Our team is dedicated to supporting you every step of the way.

• Call us at 307-283-3970 for more information.
• Schedule an appointment with your primary care provider to discuss adding BHI services to your care plan.

Together, we can build a foundation for lasting wellness.

Medicare Annual Wellness Visits (AWV)

At CCMSD, we are committed to keeping Medicare patients healthy and independent through our Medicare Annual Wellness Visits (AWV) program. These visits are focused on preventive care, giving you the opportunity to review your health, address risks, and create a personalized plan to maintain your well-being.

What’s Covered in an AWV?

Comprehensive Health Review

We’ll go over your medical history, current medications, and any ongoing treatments to get a full picture of your health.

Risk Assessment

We assess your risks for common conditions like heart disease, diabetes, and other chronic illnesses. Identifying potential issues early means they can be managed proactively.

Preventive Screenings

We ensure you’re up to date on important health screenings and vaccinations. These may include:

• Blood pressure and cholesterol checks
• Cancer screenings (e.g., mammograms, colonoscopies)
• Cognitive health assessments to monitor memory and mental sharpness
• Fall risk evaluations to help prevent injuries

Personalized Prevention Plan

Based on your health needs, we create a prevention plan tailored just for you. This plan includes lifestyle changes, follow-up care, and strategies to keep you healthy and thriving.

Advance Care Planning

If you choose, we can also discuss advance care planning to ensure your healthcare preferences are documented and honored.

Why Choose an AWV?

• Fully Covered by Medicare Part B: Medicare covers 100% of the cost of your Annual Wellness Visit, so there’s no out-of-pocket expense for you.
• Proactive Care: Address potential health issues before they become serious.
• Personalized Attention: Receive a care plan tailored to your unique needs.
• Improved Quality of Life: Stay ahead of health risks and focus on prevention.

Who Is Eligible?

Medicare patients who have had Part B coverage for more than 12 months are eligible for an Annual Wellness Visit. This is not the same as a traditional physical exam—it’s focused on prevention and long-term health planning.

What to Bring to Your Visit

• A list of current medications, including dosages
• Your family medical history
• Information about any recent health changes or concerns

Schedule Your AWV Today

Taking charge of your health has never been easier—or more affordable. With Medicare Part B covering the entire cost of your Annual Wellness Visit, there’s no reason to wait.

Call us at 307-283-3970

Your health is our priority—let’s work together to keep it that way.

Community Health Integration (CHI)

At CCMSD, we understand that health is influenced by more than just medical care. Our Community Health Integration (CHI) program is designed to connect patients with local resources and services that address the social, economic, and environmental factors affecting their well-being.

By focusing on these social determinants of health, we help ensure patients have the support they need to live healthier, more fulfilling lives.

What Is CHI?

Community Health Integration bridges the gap between healthcare and the essential services that impact daily living. Whether it’s access to nutritious food, reliable transportation, or emotional support, CHI is here to help you navigate these challenges and find practical solutions.

How We Can Help

Access to Local Services

We partner with community organizations to connect patients with resources such as:

• Transportation: Reliable options to get to and from medical appointments or essential errands.
• Food Security Programs: Access to food pantries, meal delivery services, and nutrition education programs.
• Financial Assistance: Guidance on applying for benefits or programs to ease financial burdens.
• Housing Support: Resources for finding safe, stable, and affordable housing.

Support Groups and Counseling

We link patients with local support groups or counseling services to address mental health needs, chronic illness management, or life challenges.

Education and Advocacy

Our team provides education on available programs and advocates on your behalf to ensure you receive the care and resources you deserve.

Navigation Assistance

Navigating healthcare and community resources can be overwhelming. We help you coordinate services and simplify the process so you can focus on your health.

Why CHI Matters

Addressing the social determinants of health can lead to:

• Improved Health Outcomes: A stable, supportive environment can enhance physical and mental health.
• Reduced Stress: Knowing help is available can ease the burden of daily challenges.
• Increased Access to Care: Transportation, food security, and other services remove barriers to receiving medical care.
• Stronger Community Connections: By linking you to local resources, we help you feel more supported and empowered.

How to Get Started

If you or a loved one needs assistance with connecting to community resources, our CHI team is here to help.

• Call us at 307-283-3970 to speak with one of our care coordinators. 
  

At CCMSD, we believe that health starts where you live, work, and thrive. Let us help you build a stronger foundation for wellness.