Care Coordination participants on five or more chronic medications or not at treatment goals for asthma, diabetes, hyperlipidemia, or hypertension will be referred for a CMM visit.
Patients of the INTEGRIS Health Partners PHSO network who are attributed under value-based payor agreements
A CMM visit can be scheduled based on a direct referral from the physician, care coordinator, or patient. Referral for an initial CMM visit can be made by sending a referral through Epic (“Ambulatory Referral for Comprehensive Medication Management”) or faxed referral form available for non-EPIC users upon request.
Services Offered:
Initial comprehensive medication management (CMM) visits include a comprehensive medication history and review; assessment of safety and efficacy of drug therapy, drug interactions, compliance, and costs; and medication education.
Follow-up CMM visits are scheduled based on a physician referral order to collaborate in the longitudinal management of asthma, diabetes, hyperlipidemia, and hypertension.
