Chronic Care Management: Because Great Healthcare Doesn’t End at Your Appointment
When most people think about healthcare, they think about the time they spend with their provider during an office visit.
But what happens between those appointments?
For patients living with multiple chronic conditions, that’s often when the biggest challenges arise. Questions about medications. New symptoms. Difficulty managing treatment plans. Coordinating care between specialists. Making sense of lab results. Recovering after a hospital stay.
That’s where Chronic Care Management (CCM) makes a meaningful difference.
At Lake Country Medical Group, our Chronic Care Management program is designed to provide ongoing support for eligible patients long after they leave the exam room. Rather than waiting until the next appointment, our care coordination team stays connected throughout the month, helping patients navigate their healthcare journey with confidence.
What Is Chronic Care Management?
Chronic Care Management is a Medicare-supported program designed for patients living with two or more chronic health conditions that are expected to last at least 12 months or for the remainder of their lives.
The goal is simple: provide continuous support that helps patients stay healthier, avoid unnecessary hospitalizations, and better manage their conditions every day.
Our CCM team works closely with patients by:
- Coordinating care between primary care providers, specialists, hospitals, and pharmacies
- Reviewing medications and helping patients stay on track
- Answering healthcare questions between appointments
- Following up after hospitalizations or emergency room visits
- Helping patients understand and manage chronic conditions
- Identifying concerns early before they become bigger health issues
- Developing and updating personalized care plans
- Connecting patients with community resources when needed
It’s healthcare that extends beyond the office visit and provides peace of mind knowing there’s a dedicated team available to help every step of the way.
A Program Built on Compassion
Behind every successful care coordination program is a team committed to serving patients with compassion, consistency, and excellence.
Over the past several years, Alicia Ramfos has played a vital role in building and leading Lake Country Medical Group’s Chronic Care Management program. Under her leadership, the program has grown into an essential part of how we care for patients beyond the walls of our offices.
Alicia’s dedication to patient-centered care, innovation, and collaboration has helped create a program that has positively impacted countless patients and families throughout our community.
Today, Alicia has transitioned into a new role focused on Population Health and Business Development, where she continues helping Lake Country Medical Group expand its services and strengthen the care we provide throughout the Lake Country. While her responsibilities have evolved, the patient-first philosophy she established remains the foundation of our CCM program.
Welcoming Eden Wages
As our Chronic Care Management program continues to grow, we’re excited to welcome Eden Wages as our new CCM Program Director.
Although Eden is stepping into a new leadership role, she is certainly not new to the program. This August marks three years with Lake Country Medical Group, and during that time she has been an integral member of our Chronic Care Management team.
Many patients may recognize Eden from her work in medication management and pharmacy services, but throughout her time with LCMG she has gained experience in virtually every aspect of Chronic Care Management. From working directly with patients to supporting care coordination behind the scenes, she has developed a deep understanding of the program and the people it serves.
That experience makes Eden uniquely prepared to lead the program forward. She understands that great healthcare isn’t just about treating illness, it’s about building relationships, staying connected, and helping patients feel supported every day between appointments.
Working alongside the outstanding team that Alicia helped build, Eden is committed to continuing the tradition of compassionate, personalized care while helping the program continue to grow and evolve.
Care That Never Stops
“Healthcare doesn’t happen only during office visits. Some of the most important care takes place between appointments, and that’s exactly why our Chronic Care Management team exists,” says Dr. Nicolas Chronos. “By staying connected with our patients throughout the month, we’re able to answer questions, identify concerns early, coordinate care, and ultimately help people live healthier lives.”
At Lake Country Medical Group, we believe great healthcare is built on relationships, communication, and continuity of care.
Whether you’re managing heart disease, diabetes, high blood pressure, COPD, or multiple chronic conditions, our Chronic Care Management team is here to help you stay connected, informed, and supported throughout your healthcare journey.
Because exceptional healthcare doesn’t end when your appointment is over.
It continues every day in between.
Could You Benefit from Chronic Care Management?
If you have Medicare and are living with two or more chronic health conditions, you may qualify for our Connected Care Management program. Through our Connected Care Institute, our team provides ongoing support between office visits, including personalized care planning, medication management, care coordination, and regular check-ins designed to help you better manage your health.
To learn more about our Connected Care Institute and our Chronic Care Management program, Click Here:
Or call Lake Country Medical Group at (706) 485-4004 to speak with a member of our team and learn whether Chronic Care Management is right for you.
