Chronic Care Management for Older Adults

What chronic care management means

If you are living with two or more ongoing health conditions, you may benefit from a structured plan that keeps your care connected, safe, and focused on your goals. Chronic care management brings together your primary doctor, specialists, pharmacists, therapists, and community services so your needs and preferences guide every step. You get help between visits, not only during appointments, so small issues are addressed before they become emergencies

Who benefits

You may benefit if you have conditions such as diabetes, heart disease, COPD, arthritis, kidney disease, neurologic conditions, or depression. Many older adults live with more than one condition, which can make daily life and medical decisions complicated. Coordinated support can reduce confusion, lower risk from medications, and help you stay independent

How it works

A strong approach centers on a written care plan that lists your conditions, medicines, providers, supports, and goals. You receive ongoing check ins, help after hospital or rehab stays, and a clear path for questions. Your plan should be easy to understand, shared across your care team, and reviewed regularly

The core elements of a strong plan

Coordinated primary care with specialty support

Your primary care clinician leads the plan, shares updates with specialists, and helps you weigh choices. Good coordination means your story is known, your preferences are respected, and information reaches the right person at the right time

A personalized care plan you can use

Keep a one page summary that lists diagnoses, allergies, current medicines with doses, devices, recent tests, and top goals. Bring it to every visit. Ask your team to update it after each change so everyone stays aligned

Medication review and safety

Older adults are more likely to take several medicines. Regular medication reviews can identify drugs that are no longer needed, risky combinations, duplicate therapies, or side effects that feel like new illnesses. You can ask about safer alternatives, lower doses, or deprescribing plans. Track all prescriptions, over the counter products, and supplements in one list

Self management and daily routines

Small daily habits add up. Gentle activity most days, a balanced diet, good sleep, and stress reduction support most chronic conditions. Simple trackers for blood pressure, blood sugar, weight, or symptoms help you and your team spot trends. If your clinician offers remote monitoring, connected devices can alert your team to changes sooner

Falls prevention and home safety

Falls are common and preventable. Build strength and balance with activities your clinician approves, clear tripping hazards, improve lighting, review vision and hearing, and ask whether any medicines increase fall risk. If needed, add grab bars, non slip mats, and railings. A home checklist makes this easier

Transitions of care

After a hospital or rehab stay, you should have a plain language summary of what happened, new medicines, what to watch for, and who to call. Plan a timely follow up visit. Ask for help arranging equipment, home health, or therapy if needed

Behavioral health and caregiver support

Mood, memory, and energy affect every part of health. Share concerns about anxiety, low mood, loneliness, or thinking changes. Caregivers need support too. Short breaks, peer groups, and clear call plans can lower stress and improve safety

Social needs and access

Missing visits or medicines often happens because of cost, transportation, or confusion about directions. Ask for help with ride planning, financial assistance, and step by step instructions that match your routine and language

Medicare Chronic Care Management at a glance

If you have Medicare and at least two chronic conditions, you may qualify for monthly support from your clinician’s office. This includes a comprehensive care plan, help between visits, medication review, and support when you move between care settings. You give consent to enroll, and only one clinician can bill for these services each month. There can be a small Part B cost share unless you have supplemental coverage, so ask about your costs before you enroll

Practical steps you can take today

Build your personal health snapshot

Create a simple page that lists your conditions, surgeries, allergies, current medicines and doses, devices, key providers with phone numbers, and two or three life goals that matter most to you. Keep a copy on your phone and in your wallet. Share it at every visit

Prepare for every visit

Write your top three questions. Bring your pill bottles or an updated list. Ask your clinician to explain next steps in plain language and repeat back what you heard to confirm. Request printed instructions you can follow at home

Make medicines safer

Use one pharmacy if possible. Ask for a yearly medication review or sooner after any hospital stay. Use a pill organizer, set reminders, and note any side effects right away. Never stop a long term medicine without medical advice

Move more and sit less

Aim for regular activity your clinician approves such as walking, gentle cycling, or tai chi. Short sessions count. Add balance and strength work a few days each week. Start slowly and build up

Prevent falls at home

Clear clutter, secure cords and rugs, add night lights, install grab bars where needed, and wear supportive shoes. Schedule eye and hearing checks. Ask about a home safety check or physical therapy for balance

Use simple technology

A patient portal can help you view results, message your care team, request refills, and keep your information organized. Connected blood pressure cuffs, scales, or glucose meters can share readings with your team when appropriate

Support your caregiver

Share the plan, delegate tasks, and build a backup list of helpers. Caregivers should plan breaks and seek support groups or respite resources

When to seek extra support

Consider added help from a care manager or patient advocate if any of the following feel familiar

• You have many medicines and feel unsure which ones you still need
• You are seeing several specialists and worry that advice conflicts
• You had a recent emergency visit or hospital stay
• You are missing visits or refills because of cost, transportation, or confusion
• You want help setting goals and staying on track between visits

FAQ: Chronic Care Management

• What is chronic care management?
  Chronic care management is structured support for people who live with two or more ongoing health conditions. It connects your primary doctor, specialists, pharmacists, therapists, and community services so your care is coordinated, safer, and guided by your goals. You get help between visits, not only when you are in the office.
• Who can benefit from chronic care management?
  You may benefit if you have conditions such as diabetes, heart disease, COPD, arthritis, kidney disease, neurologic conditions, or depression. Many older adults have more than one condition, which can make daily life and medical decisions complicated. A coordinated plan can reduce confusion, lower medication risks, and help you stay independent.
• How is chronic care management different from regular primary care?
  Regular primary care often focuses on individual visits. Chronic care management adds a written care plan, regular check ins, support after hospital or rehab stays, and help with questions between visits. It is designed to connect all parts of your care instead of leaving you to manage everything alone.
• What is in a good chronic care management plan?
  A strong plan lists your diagnoses, medicines and doses, allergies, devices, key providers and contacts, recent tests, warning signs, and personal goals. It should be easy to understand, updated often, and shared with your whole care team and your caregivers.
• Why are medication reviews so important?
  Many people with chronic conditions take several medicines. Regular reviews can identify drugs that are no longer needed, risky combinations, duplicate therapies, or side effects that feel like new illnesses. This helps prevent harm and may simplify your regimen. Always keep one complete list of prescriptions, over the counter medicines, and supplements.
• How does chronic care management support daily routines and self care?
  Your team can coach you on small daily habits that add up over time, such as gentle activity, balanced meals, sleep routines, and stress reduction. Simple tracking of blood pressure, blood sugar, weight, or symptoms can help you and your clinicians notice trends. Some programs offer remote monitoring so connected devices can send readings directly to your team.
• What about falls prevention and home safety?
  Falls are common and often preventable. Chronic care management can include strength and balance exercises, home safety checklists, reviews of medicines that increase fall risk, and suggestions like grab bars, non slip mats, better lighting, and supportive shoes. Vision and hearing checks also play a role.
• How are hospital or rehab stays handled in chronic care management?
  After a stay, you should receive a clear summary of what happened, what changed, which medicines to take, what to watch for, and who to call. Your team can help schedule a follow up visit and arrange equipment, home health, or therapy. This reduces the risk of going back to the hospital.
• Does chronic care management include mental health and caregiver support?
  Yes. Mood, memory, and energy affect every part of health. Your plan should make space for concerns about anxiety, low mood, loneliness, or thinking changes. Caregivers can also receive guidance, breaks, and clear call plans to lower stress and improve safety.
• Can chronic care management help with cost, transportation, or confusion about instructions?
  Yes. Many missed visits and missed medicines are due to practical barriers. Your team can help with ride planning, financial assistance resources, and step by step instructions in your preferred language and format so your plan fits your real life.
• What is Medicare Chronic Care Management?
  If you have Medicare and at least two chronic conditions, you may qualify for monthly chronic care management services from one clinician’s office. These services usually include a comprehensive care plan, help between visits, medication review, and support during care transitions. There may be a small Part B cost share unless you have supplemental coverage, so ask about your specific costs before you enroll.
• How is Chronic Care Management different from home health?
  Chronic care management is ongoing support from your clinician’s office, mostly by phone or electronic contact, focused on planning and coordination. Home health sends nurses or therapists to your home for a limited time when you meet certain medical criteria. Some people use both at different times.
• What if I already see several specialists?
  You can still benefit from a primary care clinician who leads the overall plan, pulls all the advice together, and helps you weigh tradeoffs across conditions. Chronic care management makes sure your specialists are not working in separate silos.
• What if I have memory changes or a diagnosis like dementia?
  Chronic care management can involve a trusted caregiver in visits, provide written instructions, and emphasize medication safety and falls prevention. A clear, shared plan at home can help everyone remember what to do and whom to call.
• When should I ask for extra support such as a care manager or patient advocate?
  Consider added help if you have many medicines and are unsure what you still need, see several specialists and worry that advice conflicts, recently had an emergency visit or hospital stay, miss visits or refills because of cost or transportation, or want help setting goals and staying on track between visits.
• When should I call my care team or emergency services?
  Contact your care team promptly for concerning changes that are not life threatening, such as new side effects, increasing shortness of breath, or worsening swelling. Call emergency services right away if you have chest pain, severe shortness of breath, sudden one sided weakness, new confusion, or any sudden and severe symptom.

References

• Centers for Medicare and Medicaid Services. Chronic Care Management Services booklet. June 2025. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf
• Centers for Medicare and Medicaid Services. Chronic care management services overview for people with Medicare. https://go.cms.gov/2eG6KEH
• Centers for Medicare and Medicaid Services. Chronic Care Management Fact Sheet. https://www.cms.gov/files/document/chronic-care-management-factsheet.pdf
• Agency for Healthcare Research and Quality. Care Coordination. https://www.ahrq.gov/ncepcr/care/coordination.html
• Agency for Healthcare Research and Quality. Care Coordination research and tools. https://www.ahrq.gov/ncepcr/research/care-coordination/index.html
• Agency for Healthcare Research and Quality. Patient portals and engagement summary. https://digital.ahrq.gov/2019-year-review/research-summary/patient-engagement-improves-care-and-shared-decision-making
• Agency for Healthcare Research and Quality. Patient portal eLearning program for older adults with chronic illness. https://digital.ahrq.gov/ahrq-funded-projects/theory-based-patient-portal-elearning-program-older-adults-chronic-illnesses
• Centers for Disease Control and Prevention. Fast facts on chronic disease. https://www.cdc.gov/chronic-disease/data-research/facts-stats/index.html
• Centers for Disease Control and Prevention. Older adults indicator definitions. https://www.cdc.gov/cdi/indicator-definitions/older-adults.html
• Centers for Disease Control and Prevention. Medication safety and your health. https://www.cdc.gov/medication-safety/about/index.html
• Centers for Disease Control and Prevention. STEADI older adult fall prevention. https://www.cdc.gov/steadi/index.html
• Centers for Disease Control and Prevention. About older adult fall prevention. https://www.cdc.gov/falls/about/index.html
• National Institute on Aging. Exercising with chronic conditions. January 2025. https://www.nia.nih.gov/health/exercise-and-physical-activity/exercising-chronic-conditions
• National Institute on Aging. Talking with your older patients. https://www.nia.nih.gov/health/health-care-professionals-information/talking-your-older-patients
• National Institute on Aging. Getting started with caregiving. https://www.nia.nih.gov/health/caregiving/getting-started-caregiving
• National Institute on Aging. Falls and falls prevention. https://www.nia.nih.gov/health/falls-and-falls-prevention
• National Institute on Aging. Taking medicines safely as you age. https://www.nia.nih.gov/health/medicines-and-medication-management/taking-medicines-safely-you-age
• American Geriatrics Society. Medications and older adults public translation and alternatives aligned with the 2023 AGS Beers Criteria. https://www.americangeriatrics.org/files/documents/beers/BeersCriteriaPublicTranslation.pdf
• Cleveland Clinic Consult QD. Incorporating remote patient monitoring into care. https://consultqd.clevelandclinic.org/incorporating-remote-patient-monitoring-into-care
• National Library of Medicine PubMed Central. Self management of multiple chronic conditions by community dwelling older adults. https://pmc.ncbi.nlm.nih.gov/articles/PMC7774451
• National Library of Medicine PubMed Central. Patient portal as a tool for enhancing patient experience and quality. https://pmc.ncbi.nlm.nih.gov/articles/PMC5302860
• Centers for Disease Control and Prevention. Check for Safety home fall prevention checklist. https://www.cdc.gov/steadi/pdf/steadi-brochure-checkforsafety-508.pdf

Related Understood Care resources

• Understood Care. Chronic Care. https://understoodcare.com/care-types/chronic-care
• Understood Care. Care Coordination. https://understoodcare.com/care-types/care-coordination
• Understood Care. Appointments. https://understoodcare.com/care-types/appointments
• Understood Care. Transportation Help. https://understoodcare.com/care-types/transportation-help
• Understood Care. Lower Costs of Medication. understoodcare.com/care-types/lower-costs-of-medication
• Source notes for key facts
  Medicare Chronic Care Management supports people with at least two ongoing conditions and includes a comprehensive care plan and monthly services, with possible Part B cost sharing. CMS+1CMS
  Care coordination improves safety and effectiveness by organizing activities and sharing information across the team. AHRQAHRQ Digital
  Most older adults live with at least one chronic condition and many live with more than one. CDC
  Regular physical activity tailored to your condition benefits most older adults. National Institute on AgingMayo Clinic
  Falls are common among older adults and can be reduced with exercise, medication review, and home safety changes. National Institute on AgingCDC+1

This content is for education only and does not replace professional medical advice. If you have new weakness, severe pain, fever with confusion, chest pain, or trouble breathing, call emergency services.