Chronic Care

Managing your health starts at home. We're here to help by providing a Health Coach, or someone local looking out for you. Patients are eligible for Chronic Care Management Services when they have two or more chronic conditions expected to last at least 12 months. Norton County Hospital realizes these patients may need professional health advice and assistance to best deal with these conditions. Our Health Coach can be that person to continue to help patients manage these conditions in the home.


Chronic Care Management Services pick up when Transitional Care Management ends. The Health Coach is a licensed professional who can assist patients in any required long-term (12 months or longer) follow-up care. Patients can expect these services provided by the Health Coach:

Chronic Care Management Services will be supervised by your primary care provider (at Norton Medical Clinic) and provided by the Health Coach. Norton County Hospital works with the Kansas Heart and Stroke Collaborative to provide these services. Chronic Care Management Services qualify for Medicare/Medicaid reimbursement.


Norton County Hospital also works with CareHarmony to enhance its Chronic Care Management Program. CareHarmony works on behalf of our patients by providing them a helping hand between office visits.

Our CareHarmony care coordination service is designed to help you take care of you! You will benefit by receiving monthly telephone assistance in between your regular appointments. This includes a dedicated Care Coordinator, provided by CareHarmony, to guide you toward better health. The CareHarmony team works with you as the patient and with our Norton County Hospital and Norton Medical Clinic staff.

Each month your Care Coordinator will call you to:

There is also a 24/7 Care Coordinator Phone Line to help answer any questions you may have day or night outside of your calls with your Care Coordinator.

Cost and Coverage

This service is covered by Medicare and is subject to your annual deductible and coinsurance (usually 20 percent). If you have a secondary or supplemental insurance plan, your coinsurance may be covered. It is best to review exactly what your insurance plan covers.

You are able to opt out of Chronic Care Management services through CareHarmony at any time; there are no strings attached.

Contact Us

If you have questions about this service and would like to learn more on this program, or how to enroll, please call 785-874-2261 to speak with a Care Coordinator.

Find out more about CareHarmony here.

CareHarmony CCM FAQs

What is Chronic Care Management? Chronic Care Management is a care coordination program designed by Medicare to help patients better manage their chronic conditions. It was designed to give you greater support and access to care between office visits, even while at home.

What is a chronic condition? A chronic condition is an ongoing, long-lasting health condition, which will require continual management and treatment. Left untreated, a chronic condition can hinder independence and negatively impact health. A few examples of chronic conditions include asthma, diabetes, arthritis, hypertension and heart disease.

What is care coordination? Care Coordination is the deliberate organization of patient care activities and sharing information among all of the participants concerned with a patient's care to achieve safer and more effective care. Care Coordination services (like those that are part of Medicare’s Chronic Care Management program) provide extra layers of support and care between doctor visits to eligible patients who have two or more chronic conditions.

Who is eligible? To be eligible for the Chronic Care Management program you must be a Medicare beneficiary and have multiple (two or more) chronic conditions expected to last at least 12 months, or until end of life. If you are unsure if your conditions qualify contact your primary care provider and they will be able to assist you further.

Do I have to be a Medicare member? Yes. At this point the program is only being offered to Medicare patients.

Why does my doctor want this for me? Managing and coordinating care can be especially difficult if you suffer from multiple chronic conditions. You may be seeing different types of doctors or taking several medications. For every medication you take, it’s important to know how it reacts with other medications. For every doctor you see, there are test results or health information that needs to be shared. When your care is coordinated properly, your doctors get the information they need when they need it.

But what if I feel fine? One of the great benefits of Chronic Care Management is not only to help you achieve good health, but also to maintain it. That’s why the program also focuses on things like helping you keep on top of preventive care and helping you locate specialists, valuable health care resources and community services.

What does this program cost? The majority of Medicare patients has secondary insurance, which often covers Chronic Care Management (CCM) program copays. In instances where this isn't the case, CCM may be subject to a modest copy (usually 20%), as well as your deductible. It is best to review exactly what your insurance plan covers.

Is my information private and secure? Yes. The same rules that protect your medical information in your doctor’s practice apply here as well. Your information is and will always be secure using the latest Certified Information Technology and following all HIPAA guidelines.

Why should I enroll? Chronic Care Management extends your care outside of the four walls of your physician's practice to help you maintain the best possible health. You will be matched with a dedicated care coordinator and have access to help 24/7. A treatment plan (care pathway) will be created to plan for your ongoing care and better address all your health-related issues. Your care coordinator will be there for you helping you navigate the healthcare system, including scheduling appointments, helping with refills and answering lingering questions. Your care coordinator acts as an extension of your doctor and helps your doctor monitor and adjust your care accordingly.

How do I enroll? Give us a call at 785-874-2261 to learn more about how you can benefit from this program and to gain answers to any questions you may have.

How do I opt-out of the program? With Chronic Care Management, there is no long-term commitment. You may opt-out any time by notifying us via phone. After filling out a form, you will be unenrolled at the end of the current month.

Lana Jones, LPNHours and Contact Information

Monday - Friday 8 a.m. to 4:30 p.m.

For more information, contact:
Lana Jones, LPN
Health Coach
Phone: 785-877-3305
Fax: 785-877-2841

Helpful Links

Kansas Clinical Improvement Collaborative - Information for Patients