Understood Care
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
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.
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.
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
https://understoodcare.com/healthcare-info/common-neuropathy-medications-and-what-to-watch-for
https://understoodcare.com/healthcare-info/neuropathy-treatment
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
https://understoodcare.com/transportation-help
https://understoodcare.com/care-types/mobility-equipment
https://understoodcare.com/healthcare-info/home-safety-and-accessibility
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
https://understoodcare.com/healthcare-info/financial-help
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 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 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.
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.
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.
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.
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:
If you are ready to have someone walk this journey with you, start here
https://understoodcare.com/
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.
This content is educational and is not a substitute for medical advice. Always consult your healthcare provider for personalized care.
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