Navigating Chronic Conditions Together

What this guide covers and who it is for

If you are living with a long term condition like heart disease, diabetes, Parkinson’s, COPD, or a combination of several, you know that the day to day work rarely happens in one office. There are primary care visits, specialist referrals, tests, new prescriptions, insurance approvals, and the need for transportation or home equipment. This guide explains how advocates and clinical teams can work together so you are not carrying the coordination alone. We also describe newer Medicare covered services that support navigation and community based help, and we link to resources that can make daily life easier. Chronic diseases are conditions that last a year or more and require ongoing medical attention or affect daily activities. They are very common and a leading cause of illness and cost in the United States.

You will also find links to Understood Care resources that show what this support looks like in practice
https://understoodcare.com/
https://understoodcare.com/care-types/mobility-equipment
https://understoodcare.com/transportation-help
https://understoodcare.com/healthcare-info/financial-help
https://understoodcare.com/healthcare-info/caregiver-support

How your advocate walks with you

Plain language help and a steady point of contact

You should not have to decode medical terms or repeat your story to every office. Your advocate keeps a simple summary of your conditions, current medicines, allergies, recent tests, and care goals. They prepare questions with you before visits and help you send updates to your clinicians after visits so the next step is clear.

Scheduling and referrals that actually move forward

A common barrier is a stalled referral or a specialist that is out of network. Your advocate can call the clinic, send the referral again, confirm fax numbers, and ask for the earliest appointment that matches your needs. If you need a new primary care clinician or a different specialist, your advocate helps you compare options and schedule.

Medication organization and safety

Many people with chronic conditions take several medicines. Your advocate can help you keep one clean list that includes every prescription, over the counter medicine, and supplement. They can organize reminders, help you understand which medicines must not be stopped suddenly, and encourage you to ask your clinician about side effects, interactions, or duplicate therapies. Structured medication reviews and reconciliation programs have been shown to reduce adverse drug reactions in older adults, which is one reason your team will focus on a complete and accurate list at each transition.

See practical medicine safety explainers at Understood Care
understoodcare.com/articles/common-neuropathy-medications-and-what-to-watch-for
understoodcare.com/articles/neuropathy-treatment-evidence-based-relief-and-supportive-care

Transportation, equipment, and home supports

Getting to care and staying safe at home are part of good health. Your advocate can help set up rides to and from visits and coordinate wheelchair accessible transportation when needed. If you need a walker, power wheelchair, scooter, or home safety changes, your advocate can help coordinate evaluations, gather documents your insurer requires, and connect you with vendors.

Explore these step by step guides
Transportation Help

Mobility Equipment ‍‍
Home Safety & Accessibility

Financial help and benefits

Costs can add stress and cause people to delay care. Your advocate can help you review options such as Medicare Savings Programs, pharmaceutical assistance, hospital financial assistance, and community programs that reduce costs. Start here
understoodcare.com/articles/financial-help-for-your-healthcare-needs

Newer Medicare covered services that support you

Medicare added several navigation and community focused services that can work alongside your medical visits. These services are performed by clinicians and trained auxiliary personnel such as patient navigators, community health workers, or peer specialists and are billed by your clinician’s practice.

Community Health Integration

Community Health Integration helps when non medical barriers interfere with care. After an initiating visit with your clinician, auxiliary personnel can help with things like connecting you to food support, arranging transportation, or solving insurance hurdles. These services began January 1, 2024 under HCPCS G0019 and G0022.

Principal Illness Navigation

Principal Illness Navigation supports people with a single serious high risk condition expected to last at least three months. After an initiating visit that sets the plan, auxiliary personnel provide monthly help with education, coordination, and navigation related to that condition. Medicare adopted these G codes beginning January 1, 2024. Examples of conditions include cancer, COPD, heart failure, dementia, and substance use disorder.

How these services fit with chronic care management

If you have two or more chronic conditions that are expected to last at least twelve months and that place you at risk of decline, your clinician may also offer chronic care management. This includes a comprehensive care plan, support for transitions between settings, and help reviewing medicines and services.

Together, these programs can give you regular contact between visits, bring social supports into the plan, and reduce the burden of coordination on you and your family.

Bring the video message to life in your plan

Our video explains that navigation is new to Medicare and that your advocate works alongside your primary care gatekeeper to keep everyone aligned. Here is how that looks in daily life.

Before visits

• Set one clear goal for each visit such as discuss dizziness or review swelling
• Prepare a short timeline of recent symptoms and tests
• Confirm that referral notes and imaging are at the clinic before you arrive
• Arrange transportation and mobility support

During visits

• Share your top questions early
• Ask your clinician to list the next steps with who does what and by when
• Request written instructions in simple language
• If a new medicine is started, ask how to take it, what to watch for, and when to follow up

After visits

• Your advocate sends a short update to your primary care clinician and any relevant specialists
• Your medicine list is updated the same day
• Any new referrals, equipment requests, or home supports are started within two business days
• You receive a reminder for follow up and a way to reach your advocate with questions

Practical plays for common conditions

Heart disease

• Know your plan for medicines such as statins or blood pressure drugs and ask how they protect you over time
• Cardiac rehabilitation combines education, exercise, and support and improves outcomes
• Ask about nutrition, activity, and smoking cessation resources
• If you have angina or a recent procedure, confirm the action plan for chest discomfort and when to call 911
  Evidence based care for coronary disease includes lifestyle changes, medicines, and sometimes procedures, all tailored to symptoms and risk. Cardiac rehabilitation adds education, supervised exercise, and emotional support.

Diabetes

• Build a simple routine for glucose checks, medicines, meals, and movement
• Ask about diabetes self management education and support and medical nutrition therapy
• Review foot care, eye exams, kidney labs, and blood pressure targets
  Diabetes self management education and support improves A1C and confidence and is a covered benefit in many cases. Work with your team on a plan that matches your life.

Parkinson’s disease

• Keep a consistent medicine schedule and set reminders to avoid missed doses
• Ask about physical therapy, speech therapy, and activities like tai chi or dance for balance and confidence
• If medicines no longer control symptoms well, ask if you should review options such as device aided therapies with a specialist
  Most people are managed with combinations centered on levodopa and carbidopa, plus therapies that support movement, speech, and daily life.

Safer care at transitions

Hospital discharge, a new specialist, or a change in residence are times when details can get lost. Ask your team to do a complete medication reconciliation and to send an updated list to you and all clinicians. Structured transitional care programs and follow up calls are associated with meaningful reductions in readmissions, especially when the plan is clear and timely.

When you feel overwhelmed

It is normal to feel frustrated or tired when conditions pile up or when the system does not move as quickly as you need. You do not have to do this alone. Your advocate and clinical team can:

• Translate medical advice into a simple daily plan
• Coordinate appointments so you are not bounced between offices
• Keep your medicine list accurate and watch for interactions
• Arrange rides, equipment, and home supports
• Help you apply for programs that reduce costs and stress

If you are ready to have someone walk this journey with you, start here
https://understoodcare.com/

How to work with your advocate

Prepare

• Share your top three goals
• Bring your medicine bottles or a photo of each label
• List your allergies and any side effects you have noticed
• Share barriers such as transportation, home layout, or cost

Agree on communication

• Choose your preferred way to talk and your backup
• Decide how often you want check ins
• Ask for a simple summary after each step so you always know what is next

Measure progress

• Track what matters to you such as walking to the mailbox, lower pain at night, or fewer urgent visits
• Review your plan every month and adjust together

Cross references to Understood Care resources

• Mobility equipment support and home safety
  https://understoodcare.com/care-types/mobility-equipment
  understoodcare.com/articles/home-safety-and-accessibility
• Transportation to and from care
  https://understoodcare.com/care-types/transportation-help
• Financial help and benefits
  understoodcare.com/articles/financial-help-for-your-healthcare-needs
• Support for family and friends who help with care
  understoodcare.com/articles/caregiver-support

Gentle reminder about coverage

Community Health Integration and Principal Illness Navigation are Medicare covered services when requirements are met. Your clinician’s office will confirm eligibility and obtain your consent. Cost sharing under Part B may apply. See the official CMS overview and FAQ for details adopted in the 2024 Physician Fee Schedule.

Coordinated Chronic Care: Frequently Asked Questions

• What does “chronic care coordination” actually mean?
  Chronic care coordination means making sure all the moving parts of your care work together instead of against each other. That includes your primary care clinician, specialists, therapists, labs, pharmacies, equipment vendors, and your insurance plan. When care is coordinated, everyone has the same up to date information, referrals move forward, medicines are reviewed for safety, and you are not left carrying all the follow up on your own.
• How does an advocate help me day to day?
  An advocate becomes your steady point of contact. They keep a simple summary of your diagnoses, medicines, allergies, recent tests, and goals. Before visits they help you decide your top priorities and prepare questions. Between visits they check that referrals were received, appointments are scheduled, and orders for equipment or supplies are actually moving forward. After visits they can help you understand what was said, update your medication list, and send a short summary back to your care team.
• What can an advocate do about referrals and scheduling problems?
  If a referral stalls or a specialist is out of network, an advocate can call the clinic, resend referral notes, confirm fax or portal details, and ask for the earliest available appointment. If you need a new primary care clinician or a different specialist, they can check which offices are in network, accepting new patients, and a good match for your needs, then book the visit and arrange reminders and transportation if needed.
• How can an advocate help with my medications and safety?
  Many people with long term conditions take several medicines from different prescribers. An advocate helps you keep one clean, current list that includes prescriptions, over the counter medicines, and supplements. They can set up a simple system for refills and reminders, encourage you to bring all medicines to visits, and prompt you to ask your clinicians about possible side effects, interactions, or duplicate treatments. Keeping this list accurate at each transition reduces the chance of medication errors or adverse reactions.
• What support is available for transportation, equipment, and home safety?
  Getting to appointments and staying safe at home are part of effective chronic care. An advocate can arrange rides to and from visits, including wheelchair accessible transportation when needed. If you need a cane, walker, rollator, scooter, or power wheelchair, they can coordinate the evaluations, gather the documents your insurer requires, and help you choose vendors. They can also connect you to resources for home safety changes such as grab bars, ramps, or other accessibility updates.
• Can an advocate help with financial stress and benefits?
  Yes. Advocates can help you explore programs that reduce costs, such as Medicare Savings Programs, pharmaceutical assistance from manufacturers, hospital financial assistance, and community based support. They can walk you through applications, track status, and explain decisions in plain language. They can also review confusing bills with you and identify when something may be incorrect or appealable.
• What are Community Health Integration and Principal Illness Navigation?
  These are newer Medicare covered services designed to address real world barriers to care. Community Health Integration focuses on non medical needs that affect health, such as transportation, food access, or insurance problems. After a clinician starts the service at an initiating visit, trained personnel such as community health workers or navigators can work with you between visits. Principal Illness Navigation supports people with a single serious, high risk condition that is expected to last at least three months. After an initiating visit, trained personnel provide ongoing education, coordination, and navigation related to that condition. Both services are billed by your clinician’s practice and can sit alongside your usual medical care.
• How do these new services fit with chronic care management?
  Chronic care management is a Medicare covered service for people with two or more chronic conditions that are expected to last at least a year and carry a risk of decline. It includes a comprehensive care plan, medication review, and support between visits. Community Health Integration and Principal Illness Navigation add focused help with social needs and condition specific navigation. Together, they can provide regular check ins, help with logistics, and a stronger safety net for people with complex needs.
• How do the video suggestions translate into real steps before and after visits?
  Before a visit, you and your advocate choose one clear goal such as discussing dizziness, swelling, or a new symptom. You put together a short timeline of what has changed and confirm that referral notes, imaging, and labs have reached the clinic. Transportation and mobility needs are arranged in advance. During the visit, you share your top questions early and ask your clinician to spell out next steps, who is responsible for each task, and when you should expect results. After the visit, your advocate helps send an update to your primary care clinician and any specialists, updates your medicine list, starts any new referrals or equipment requests, and sets reminders for follow up.
• How can this approach help with conditions like heart disease, diabetes, or Parkinson’s?
  For heart disease, coordination helps you stay on the right combination of medicines, attend cardiac rehabilitation, follow a safe activity plan, and know exactly what to do for chest discomfort and when to call emergency services. For diabetes, a coordinated approach keeps A1C testing, glucose checks, foot and eye exams, kidney labs, blood pressure management, and education on one organized track. For Parkinson’s disease, coordination helps you keep a consistent medicine schedule, access physical and speech therapy, explore programs like tai chi or dance for balance, and review advanced options with specialists if symptoms are no longer well controlled.
• Why are transitions like hospital discharge such a big focus?
  Any time you move between settings, such as leaving the hospital, seeing a new specialist, or moving to a new residence, details can be lost. Medicines may change, new instructions are added, and follow up tasks appear. Transitional care programs and careful medication reconciliation at these times are linked with fewer readmissions and safer recovery. An advocate helps you get an updated medication list, understand which medicines changed and why, confirm follow up appointments, and make sure all clinicians receive the same updated information.
• What should I do if my conditions and appointments feel overwhelming?
  Feeling overwhelmed is very common when you live with more than one chronic condition. Instead of trying to carry everything alone, you can work with an advocate and your clinical team to break things into manageable pieces. That might mean choosing your top three goals, such as better sleep, fewer urgent visits, or walking to the mailbox again, and building a plan around those. Your advocate can streamline scheduling, consolidate appointments when possible, keep your medicine list accurate, set up transportation and home supports, and help you apply for programs that lower financial stress.
• How can I get the most out of working with an advocate?
  Come into the relationship with a short list of what matters most to you. Share your top goals, your full medicine list, your allergies, and any side effects you notice. Be open about barriers such as transportation, home layout, or cost. Agree on how and how often you want to communicate, such as phone, text, or email, and ask for brief written summaries after key steps so you always know what comes next. Review progress together at least once a month and adjust the plan if your goals or health change.
• Does Medicare always cover these navigation and coordination services?
  Medicare covers services like Community Health Integration, Principal Illness Navigation, and chronic care management when eligibility criteria are met and when you give consent. They are generally billed under Part B, and normal cost sharing may apply. Your clinician’s office will confirm whether you qualify and explain any costs. An advocate can help you ask the right questions and understand how these services fit into your overall coverage.

References

• Centers for Medicare and Medicaid Services. Care Management. Page last modified April 21 2025. https://www.cms.gov/medicare/payment/fee-schedules/physician/care-management
• Centers for Medicare and Medicaid Services. Health Related Social Needs Frequently Asked Questions. Community Health Integration and Principal Illness Navigation services adopted January 1 2024. https://www.cms.gov/files/document/health-related-social-needs-faq.pdf
• Medicare.gov. Chronic Care Management Services. https://www.medicare.gov/coverage/chronic-care-management-services
• Centers for Disease Control and Prevention. About Chronic Diseases. Updated October 4 2024. https://www.cdc.gov/chronic-disease/about/index.html
• Centers for Disease Control and Prevention. Chronic Disease. https://www.cdc.gov/chronic-disease/index.html
• National Institute of Diabetes and Digestive and Kidney Diseases. Managing Diabetes. https://www.niddk.nih.gov/health-information/diabetes/overview/managing-diabetes
• Medicare.gov. Diabetes Self Management Training. https://www.medicare.gov/coverage/diabetes-self-management-training
• National Heart Lung and Blood Institute. Coronary Heart Disease Treatment. https://www.nhlbi.nih.gov/health/coronary-heart-disease/treatment
• JAMA Network Open. Transitional Care Interventions From Hospital to Community Care for Older Adults. 2023. https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2812390
• BMC Primary Care. A systematic review of chronic disease management interventions in primary care. 2018. https://bmcprimcare.biomedcentral.com/articles/10.1186/s12875-017-0692-3
• AHRQ. Medications at Transitions and Clinical Handoffs Toolkit. https://www.ahrq.gov/patient-safety/settings/hospital/match/index.html
• Gray SL et al. Interventions to optimize medication use in older adults reduce adverse reactions. 2023. https://pmc.ncbi.nlm.nih.gov/articles/PMC10600043/
• National Institute of Neurological Disorders and Stroke. Parkinson’s Disease. https://www.ninds.nih.gov/health-information/disorders/parkinsons-disease
• Mayo Clinic. Parkinson’s disease treatment. https://www.mayoclinic.org/diseases-conditions/parkinsons-disease/diagnosis-treatment/drc-20376062
• MedlinePlus Medical Encyclopedia. Chronic. Updated January 1 2025. https://medlineplus.gov/ency/article/002312.htm
• National Center for Chronic Disease Prevention and Health Promotion. Data and Surveillance. Updated May 15 2024. https://www.cdc.gov/chronic-disease/data-surveillance/index.html

This content is educational and is not a substitute for medical advice. Always consult your healthcare provider for personalized care.