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Chronic Conditions & Diseases

Chronic Conditions & Diseases

About Chronic Diseases

Chronic Conditions & Diseases
Chronic diseases are conditions that last one year or more and require ongoing medical attention or limited activities of daily living, or both. Chronic conditions such as asthma (chronic), heart disease, lung disease, kidney disease, and diabetes are the leading causes of death and disability in the United States. They are also leading drivers of the nation’s $3.8 trillion in annual health care costs. Many chronic diseases are caused by a short list of risky behaviors:

Our chronic conditions center uses a coordinated care approach to managing illness, which includes screenings, check-ups, monitoring, coordinating treatment, and patient education. Our approach can improve your quality of life while reducing your health care costs by preventing or minimizing the effects of the disease.

Your doctor or nurse practitioner working with a registered nurse are your primary partners in managing your chronic conditions. Chronic care visits are typically scheduled every three months and involve treatment with lifestyle changes and medications. Your chronic care management services team will help you set goals and check in with you frequently to measure your progress.

If you are juggling multiple or complex conditions, we have a chronic care coordination team ready to deliver your optimal coordinated care, help you achieve your goals, and troubleshoot any barriers you encounter. Complex care coordination typically involves weekly to monthly check-ins to help you manage your conditions at home.

Chronic Care Management Services, Chronic Conditions Center

Medicare and other insurance carriers pay for a healthcare provider’s help with chronic conditions management if you have two or more serious chronic conditions that are expected to last at least a year. The goal of chronic care management services is to provide you with high-quality, coordinated care to better maintain your health and functioning.

You may be eligible for care management if you have two or more chronic health conditions. A chronic health condition is a health issue that may last at least 12 months and which places you at significant risk of functional decline or death. Examples include arthritis, asthma, diabetes, and heart disease. Chronic care management services include:

  • Developing a plan of care by a health care professional or team of professionals
  • 20-60 minutes per month of care management services
  • Increased care coordination among your providers, pharmacies, and other facilities
  • Regular check-ins with you between doctor’s office visits
  • Continuous emergency access to a health care professional
  • Help with financial and social services


You may pay a monthly fee for care management services. Original Medicare cost-sharing (deductibles, copayments/coinsurances) also applies.

We have a care coordination team to help coordinate your care, achieve your goals and troubleshoot any barriers you encounter. Complex care coordination typically involves weekly to monthly check-ins to help you manage your conditions at home.

Need more info about screening and prevention at Cold Hollow Family Practice? Call us at 802-933-6664 or Request an Appointment here. We see patients of all ages from Enosburg, Richford, Franklin, Sheldon, and Swanton.

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