Chronic Care Management (CCM) is a service and benefit for Medicare Part B recipients. This service reimburses approved providers to manage patients with 2 or more chronic conditions.

Patients interested in receiving this benefit can enroll through your provider of care. You need only to verbally agree to services to initiate. Your Elite provider will take the next steps for you.

Once you agree to services, your Elite provider will gather information about you and your providers of care. Your CCM provider will spend time in the background, working for you, managing your healthcare needs.

Your Elite provider will communicate with other providers involved in your care on a regular basis.

Chronic Care Management is an approved Medicare program. This is a benefit covered under Part B Medicare.

All Medicare Part B recipients are eligible who have 2 or more chronic conditions.

We will contact you as needed. The program requirement is 20 minutes of non-face-to-face time managing your healthcare.

You may contact your Elite provider at any time. If you are experiencing an issue or have a question about your healthcare, we will respond to your need.

No. Once enrolled, you remain enrolled unless you deselect the program.

Austin Market

• Kayla Frye – TTH Case Manager – 737-226-6750
• Brittany Smith – TTH Nurse Practitioner
• Laura McGinnis – TTH Nurse Practitioner

• We accept patients with traditional Medicare
• Additional insurances currently participating in Transitional Care Medicine benefits include: Humana, Well Med (in-network), Aetna, BCBS, and Medicare Railroad
• Coverage by other insurances not listed above will need to be verified before a patient is enrolled in TTH

• Patients that have discharged from a qualifying acute care hospital, LTACH or SNF
• EPC can accept referrals for patients at any time after their admission and for patients that have been discharged no greater than 2 business days from their qualifying facilities
• Please note, we encourage referrals be sent prior to discharge.

You can send a fact sheet, current MAR, discharge summary, and necessary clinical information as follows:
Fax 737-226- 6767 OR Email to transitions@elitepatientcare.com

*Please note that EPC cannot guarantee receipt of any referral sent to us outside of these two methods.

Please call our Transitions Line 737-226-6750, and our Care Manager will be happy to assist you.

You can reach our provider team by calling MEDLINK @ 512-660-5678, 24 hours a day and 7 days a week. When calling, please make sure to notify MEDLINK you are part of the Transitions to Home Program

Once enrolled and we have physically seen the patient, we will follow the patient for up to 90 days.

• We will provide medical supervision and coverage for the full 90 days, OR
• Until the patient has re-established care with their PCP (whichever comes first)
• Our main goal is to provide a bridge for clinical care access in the timeline between discharge from a qualifying facility and their first visit with a PCP

• We will follow the patient until the time comes that they are engaged with a primary care physician
• Our team will work diligently in locating a PCP that will accept the patient

• We currently provide services in Austin, San Antonio, and Temple markets, as well as defined areas in the surrounding communities.
• Please feel free to contact our Care Manager via phone, fax, or email for a specific service area

• We will approve the original discharge orders with patients that agree to be seen in our TTH program
• Once a patient has been physically seen by one of our providers, we can sign 485 certifications, DME, and refill medication orders as deemed appropriate for their care by our providers

* We cannot sign any 485/face to face certifications for home health if we have not physically seen the patient. In an effort to provide the best care, we reserve the right to approve changes in care plans after we have conducted a proper clinical assessment.

Also, note that we can only provide clinical guidance, medical orders, and/or certifications IF the patient has enrolled in our TTH program. If a patient has declined or not enrolled, one of our team members will contact you.

Our dedicated Nurse Practitioners are consistently present in their respective communities Monday through Friday. Physician visits typically occur on a weekly basis and more often as necessary.

Patients will be seen according to clinical needs, and the frequency will be determined on an individual basis.

EPC providers can be contacted through Medlink answering services. Contacting our answering service ensures the most rapid response time as they have the most up to date information on coverage duties.

Scheduling meetings should be arranged with the facility nursing staff in coordination with EPC providers. Although we strive to accommodate family and patient needs ASAP, please allow for a reasonable time frame in which to accommodate all requests.

EPC does not provide emergent care in nursing facilities. The available resources at these sites do not allow for critical care. In case of an emergency, patients will be transported o the Hospital if indicated. We are always available for assistance via phone 24/7.

Download PDF