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Comprehensive Support for Patients Living With Multiple Chronic Conditions
At KFP, we provide proactive, coordinated Chronic Care Management (CCM) services to help patients with two or more chronic conditions stay healthier, avoid complications, and enjoy a higher quality of life.
Our patient-centered approach focuses on ongoing communication, consistent monitoring, and personalized care plans designed to meet your unique needs.
What Is Chronic Care Management?
Chronic Care Management is a Medicare-supported program that offers monthly, ongoing support for patients living with long-term health conditions such as diabetes, hypertension, COPD, heart disease, arthritis, and more. CCM helps bridge the gap between office visits, ensuring that you receive continuous guidance, medication monitoring, and lifestyle support that keeps your health on track year-round.
CCM also improves care coordination among your healthcare providers—ensuring everyone is aligned and working toward the same goals.
Why Chronic Care Management Matters
Improved Health Outcomes Through Continuous Support
Chronic conditions require consistent attention—not just an annual checkup. Our CCM program helps you stay ahead of symptoms, prevent avoidable complications, and stay engaged in your treatment plan.
Better Communication Between You and Your Care Team
Patients enrolled in Chronic Care Management receive a dedicated care coordinator and enhanced access to their healthcare team. This ensures questions are answered promptly and needs are addressed before they escalate.
Covered by Medicare
Medicare recognizes the value of ongoing care for chronic conditions. That’s why CCM services are covered for eligible beneficiaries with minimal cost sharing.
Conditions We Manage Through CCM
Our Chronic Care Management program supports patients with a wide range of chronic conditions, including:
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Diabetes & Prediabetes
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Hypertension (High Blood Pressure)
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High Cholesterol
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Chronic Obstructive Pulmonary Disease (COPD)
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Asthma
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Heart Disease & Heart Failure
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Thyroid Disorders
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Arthritis & Osteoarthritis
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Obesity & Metabolic Syndrome
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Chronic Kidney Disease
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Depression & Anxiety Disorders
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Autoimmune Conditions
If you’re living with two or more chronic conditions expected to last at least 12 months, you may qualify for CCM services at KFP Medical.
What’s Included in Our Chronic Care Management Program
We provide a comprehensive, structured care plan tailored to your health needs. Our CCM services include:
Personalized, Goal-Oriented Care Plans
Your care team builds a customized roadmap that outlines your conditions, medications, health goals, and treatment strategies.
Monthly Check-Ins
Our team reaches out monthly to review symptoms, medication needs, lifestyle changes, and any new concerns.
Medication Management
We track your medications, monitor interactions, and help ensure you stay on schedule with prescriptions.
Care Coordination Across All Providers
We communicate with specialists, pharmacies, labs, and other medical professionals involved in your care.
24/7 Access to Critical Health Information
Your detailed care plan and medical history are securely available for both you and your healthcare team.
Support Between Office Visits
When unexpected symptoms or questions arise, we’re here to assist—reducing the need for urgent care or ER visits whenever possible.
Benefits of Chronic Care Management
✔ Better control of chronic conditions
✔ Fewer hospitalizations and complications
✔ Improved medication adherence
✔ More personalized, attentive care
✔ Proactive management rather than reactive treatment
✔ Better quality of life and daily functioning
CCM empowers patients to actively participate in their health and gives families peace of mind knowing help is always available.
Is Chronic Care Management Right for You?
You may benefit from CCM if you:
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Live with two or more chronic conditions
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Want help managing medications or health goals
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Need extra support between office visits
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Experience frequent symptoms or flare-ups
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Want easier communication with your care team
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Feel overwhelmed by managing your health alone
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Receive Medicare or a Medicare Advantage plan
If this sounds like you, CCM can help you feel more supported and in control of your health.
Locally Trusted, Patient-Centered Care
KFP is committed to delivering accessible, compassionate healthcare. Our CCM program is built around your comfort, your goals, and your long-term well-being.
Experienced Care Coordination Team
Our trained care managers specialize in supporting complex conditions and providing easy-to-understand guidance.
Holistic, Whole-Person Approach
We focus on more than symptom management—we look at lifestyle, emotional well-being, daily challenges, and long-term health outcomes.
Seamless Communication
We ensure thorough chart documentation, consistent follow-ups, and prompt communication whenever your needs change.
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Dr. Cecilia Keady
DNP, FNP, APRN
Brings decades of clinical experience and is dedicated to compassionate, culturally responsive care that supports patients and families.
Luke Little
DNP, APRN, FNP-BC, CEN
Provides thoughtful primary care with a focus on prevention, chronic disease management, and patient-centered treatment.
Ashley Petrin
FNP, APRN
Passionate about preventive care, patient education, and building strong relationships that support long-term wellness.
Anna Keady
PA-C
Provides patient-centered care focused on prevention, education, and supporting the health of individuals and families.
Jamie Stone
FNP, APRN
Delivers compassionate, comprehensive care while helping patients take an active role in their health.
What Our Patients Are Saying
Real patients. Real experiences. Real support.
I have been using Keady Family Practice for many years. I can’t say enough about ALL of the staff at this practice. The office staff is always helpful, kind, prompt & professional. The health care providers are friendly, knowledgeable, and approachable
Julie J.
I’ve been coming here for a very long time. I really love this doctors office to the point where even when I moved back to NY briefly I still kept and drove up for Keady Family Practice! All the staff are very welcoming and friendly!You can get seen very quickly when an appt is needed.
Crystalanne N.
Dr. Keady, goes above and beyond to show she truly cares for her Patients as a whole. Always takes time to explain why she thinks a certain medication would be a good choice and explains the reasons for her choices. Providing time for not only questions but answers.
Pam C.
I've been coming here for years, everyone is very helpful and most all of my appointments have been on time and not much waiting. Dr Keady has always gone above and beyond for my care. Thanks so much for everything you do!
Bob N.
Who Qualifies for Chronic Care Management?
You may qualify if:
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You have two or more chronic conditions (diagnosed or clinically suspected)
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Your conditions are expected to last 12 months or longer
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You agree to participate in monthly follow-ups and care coordination
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You are a Medicare beneficiary (Traditional Medicare or Medicare Advantage programs that cover CCM)
If you’re unsure whether you qualify, our team can help determine eligibility.
Frequently Asked Questions
Chronic Care Management is a Medicare-supported program that provides monthly, ongoing support for patients with two or more chronic conditions. The CCM program includes personalized care plans, medication monitoring, regular check-ins, and continuous communication with your healthcare team to help you manage your health more effectively between office visits.
You may qualify for CCM if you have two or more chronic conditions expected to last at least 12 months and place you at risk for decline or complications. Conditions may include diabetes, hypertension, COPD, heart disease, arthritis, or other long-term health issues. CCM is available to patients with Medicare or Medicare Advantage plans that cover Chronic Care Management services.
Yes. Medicare and most Medicare Advantage plans cover Chronic Care Management for eligible beneficiaries. Typically, there is a small monthly copay, but many patients pay little to nothing depending on their insurance plan. Our team can help you understand your coverage and any associated costs.
KFP’s Chronic Care Management program supports a wide range of long-term conditions, including:
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Diabetes and prediabetes
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Hypertension
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High cholesterol
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COPD and asthma
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Heart disease and heart failure
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Arthritis and autoimmune disorders
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Thyroid disorders
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Obesity and metabolic syndrome
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Chronic kidney disease
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Depression and anxiety
If you have multiple chronic conditions, you may qualify for ongoing CCM support.-
Our CCM program includes:
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Monthly check-ins with your care coordinator
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Personalized care plans tailored to your health goals
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Medication management and refill coordination
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Communication between your providers, specialists, and pharmacies
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24/7 access to your care plan and medical information
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Support for sudden symptoms or concerns between office visits
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Preventive guidance to help avoid complications
This ensures you have continuous, proactive care that extends beyond routine appointments.
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Patients enrolled in CCM receive monthly outreach, as required by Medicare. However, you can contact your care team anytime health concerns or questions arise. Our goal is to provide consistent communication and timely support to help you stay on track.
CCM enhances your care by providing continuous oversight of your health, early identification of changes or risks, improved medication adherence, and better coordination between your healthcare providers. Many patients experience fewer hospital visits, better symptom control, and an overall improved quality of life.
Yes. Because CCM includes regular check-ins, medication monitoring, and early intervention when symptoms change, many patients experience a reduction in emergency room visits and hospitalizations. CCM helps you address concerns before they become serious.
Enrollment is simple. Talk to your KFP provider during your visit, or call our office to request Chronic Care Management enrollment. Once enrolled, you will receive monthly support and a customized care plan created specifically for your health needs.
If you are living with two or more chronic conditions and want more support between office visits, CCM is likely a great fit. Our team can review your medical history, help determine eligibility, and explain how CCM can support your long-term health goals.
Related Services
You may also benefit from these services at KFP:
Take the Next Step Toward Better Health
If you’re ready to take a proactive approach to managing your chronic conditions, our team is here to help.
Contact KFP today to learn more about Chronic Care Management or to enroll in the program.
Call 603-863-7777 or fill out our online form to learn more.
Better coordination. Better communication. Better health—every day.