Proactive chronic care management

chronic care management (CCM), defined as coordinated health care interventions and communications for populations with conditions that require significant self-care efforts.5 Proactive CCM has been widely adopted as a means to improve quality and thereby reduce unnecessary health care utilization and expenditure.

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• http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3128444/
• http://www.managedhealthcareconnect.com/article/optimistic-transition-visits-model-improve-hospital-nursing-facility-transfers