Phone-based connection. Clinician-directed care. Let’s connect

Chronic care management

For the everyday of
living with a condition.

Not every care journey starts with a discharge. Ongoing conditions can bring daily questions, changing routines and a need for better connection between appointments.

Availability. Ask about support for yourself, a loved one or your organization. Program availability is confirmed before enrollment. An enrollment coordinator helps you check availability and basic eligibility, review coverage and expected costs, and complete consent and scheduling. A participating nurse practitioner assesses your care needs and develops your care plan.

Talk with our team
An older man holding his smartphone at home

A continuing conversation around your care plan.

Chronic care management (CCM) is a clinician-provided service for eligible people with multiple chronic conditions. A care plan helps organize priorities, coordination and follow-up. Your clinical partner determines whether you qualify and explains the service, its availability and costs.

KindlyMoments’ scheduled voice check-ins are designed to complement that plan. They give you a regular opportunity to share patient-reported changes, even when there has not been a recent hospital stay.

Make space for what matters to you

  • How the day-to-day routine is going.
  • Questions about following the clinician’s instructions.
  • Changes in comfort, sleep or daily activities relevant to your care plan.
  • Appointments and practical barriers to follow-up.

These are examples of topics a clinician may select, not a diagnostic checklist or individualized medical advice.

Clinical judgment stays with clinicians.

The technology organizes answers. A licensed clinician interprets routed concerns and directs follow-up. Calls are scheduled; scheduled calls do not provide continuous or between-call monitoring or around-the-clock clinical availability.

For general background: Medicare’s chronic care management information.

Ask about ongoing support

Explore what the daily routine looks like

A little more connection.

A better next step
starts with a conversation.

Let’s find yours

Your KindlyMoments workspace

Find your space.

Explore the workspace for your role.

New here? Talk with our team. For an emergency, call 911.