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

Frequently asked questions

• How is Chronic Care Management different from home health
  Chronic Care Management provides ongoing support from your clinician’s office between visits. Home health sends nurses or therapists to your home for a short period when you meet specific criteria. Many people use both at different times
• Can I change my plan if my goals change
  Yes. Ask your team to update your plan whenever a condition flares, a medicine changes, or your personal goals shift
• What if I live with memory changes
  Involve a trusted caregiver in visits, share a copy of your plan at home, and ask for written instructions. Medication review and falls prevention are especially important
• What if I already have a specialist for each condition
  You still benefit from a primary care lead who coordinates the whole picture and helps you weigh tradeoffs across conditions

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

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.