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/care-types/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.

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
https://understoodcare.com/care-types/transportation-help
https://understoodcare.com/care-types/mobility-equipment

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.

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
  
• Transportation to and from care
  https://understoodcare.com/care-types/transportation-help

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.

FAQ

• What is a chronic condition?
  A chronic condition is a health problem that lasts a year or longer, requires ongoing medical care, and may limit daily activities. Examples include heart disease, diabetes, COPD, arthritis, Parkinson’s disease, and many others.
• What is “care management” or “care coordination”?
  Care management is extra help to organize your medical care. A care manager or navigator can help you:
  • Understand your diagnoses and treatment plan
  • Keep track of appointments and tests
  • Communicate with your doctors and specialists
  • Connect with community resources like food, housing, and transportation
  ‍
• What are Community Health Integration and Principal Illness Navigation services?
  These are new Medicare-covered services that help older adults with health related social needs. They focus on things like:
  • Access to food, housing, and transportation
  • Help understanding medical instructions
  • Support managing serious or complex illnesses over time
  ‍
• Does Medicare pay for chronic care management?
  Yes. Medicare covers certain chronic care management services for people with qualifying long term conditions. These services are usually provided by your primary care practice and may involve phone calls, care planning, medication review, and coordination between your doctors. There may be copays depending on your plan.
• How can care management help me if I have diabetes, heart disease, or another long term condition?Care management can help you:
  • Set realistic health goals
  • Understand your medications and when to take them
  • Learn about diet, exercise, and self management tools
  • Catch problems early before they become emergencies
  • Stay out of the hospital and live more independently
  ‍
• What is “transitional care,” and why is it important?
  Transitional care is support you receive when you move from one setting to another, like from the hospital back home or into rehab. Good transitional care helps to:
  • Review your medications so they are safe and correct
  • Make sure you understand discharge instructions
  • Schedule follow up appointments
  • Reduce the chance of being readmitted to the hospital
  ‍
• How can care teams help with my medications?
  Care teams can:
  • Review all your prescriptions, over the counter drugs, and supplements
  • Look for dangerous interactions or duplicate medications
  • Work with your doctor to simplify your medication list when possible
  • Help you set up pillboxes, reminders, or delivery services
  ‍
• What support is available if I have Parkinson’s disease or another complex condition?
  For conditions like Parkinson’s disease, care management may include:
  • Coordinating visits with neurology, physical therapy, and other specialists
  • Helping you understand treatment options and side effects
  • Connecting you with community programs, exercise classes, or support groups
  • Supporting caregivers and family members
  ‍
• What questions should I ask my doctor about these services?
  You can ask:
  • Do I qualify for chronic care management or care coordination services?
  • Is there someone on your team who can help me manage my conditions between visits?
  • Can you review my medications to see if they are all still needed?
  • Are there community programs that could help with transportation, food, or housing?
  ‍
• Is this information medical advice?
  No. This guide is for education only and does not replace medical advice. Always talk with your doctor, nurse, or other licensed provider about your specific health conditions, medications, and treatment options.

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.