Geriatric Internal Medicine & Medicare Chronic Care Management (CCM)
Personalized, unhurried primary care for seniors managing multiple chronic illnesses. 24/7 dedicated nurse care coordinators, home medication reviews, and wheelchair-accessible facilities.
Elderly patients navigating multiple chronic conditions—such as heart disease, type 2 diabetes, arthritis, osteoporosis, and mild cognitive impairment—often find modern healthcare fragmented and confusing. Different specialists prescribe conflicting medications, leading to dangerous drug interactions (polypharmacy) and frequent hospital readmissions. Collin Health Partners provides an integrated Geriatric Chronic Care Management (CCM) program under Medicare Part B. Our board-certified internists and dedicated clinical nurse managers oversee your entire health journey, conducting regular phone check-ins, organizing prescription refills, and synchronizing specialist care.
Who is a good candidate
- Medicare Part B beneficiaries with two or more chronic health conditions expected to last at least 12 months
- Seniors taking 5 or more daily prescription medications seeking a comprehensive drug safety audit
- Older adults experiencing mobility challenges, balance loss, or recurrent falls at home
- Family caregivers seeking an established medical home with direct physician access for elderly parents
Treatment protocol
- Step 1: 360-Degree Comprehensive Geriatric Health Audit — Evaluation of functional independence, cognitive status (Mini-Cog), nutritional health, and home safety hazards.
- Step 2: Deprescribing & Medication Reconciliation — Systematic review of all prescription drugs, over-the-counter supplements, and herbals using the Beers Criteria to eliminate high-risk medications.
- Step 3: Dedicated Monthly Clinical Nurse Coordination — Proactive monthly phone consultations monitoring blood pressure, blood glucose logs, lab scheduling, and transportation needs.
- Step 4: Hospital & Specialist Synchronization — Direct communication with hospitalists and surgeons at Texas Health Presbyterian Hospital Plano to ensure smooth post-discharge recovery.
Frequently asked questions
What is Medicare Chronic Care Management (CCM)?
CCM is an official Medicare Part B program that provides patients with two or more chronic conditions with continuous, non-face-to-face care coordination between office visits, including dedicated nurse phone support, prescription management, and 24/7 clinical access.
Are your medical clinics wheelchair accessible?
Yes. All 6 of our clinic locations feature ground-floor surface parking directly adjacent to the building entrance, automatic double doors, wide wheelchair ramps, and spacious exam suites.