Provida Family Medicine

Chronic Care Management

What is Chronic Care Management (CCM)?

Medicare has identified chronic care management as a critical component of primary care that contributes to better care for individuals who have two or more chronic health conditions.

CCM aims to improve the quality of care and health outcomes by providing them with coordinated and continuous care.


The benefits of CCM enrollment include the following:

  • 24/7 access to your primary care team.
  • Phone check-ins between office visits to keep you on track with provider orders.
  • Preventive care services are scheduled, many of which are covered by Medicare.
  • Monitoring and managing patient health and well-being
  • Medications will be closely monitored.
  • A personalized, comprehensive plan of care for all your chronic health conditions.
  • Care coordination by your physician and staff, including the care you may receive at other locations, such as specialists’ offices, the hospital, other healthcare facilities, or your home.


A breathing condition that causes a patient’s airways to become inflamed. This condition more commonly affects children. Asthma can also be present in adults. Asthma may cause chest pain, difficulty breathing, and coughing. It is mainly treated with the use of an inhaler.


Chronic Obstructive Pulmonary Disease (COPD)

Chronic obstructive pulmonary disease (COPD) is an inflammatory lung disease that is caused by obstructions blocking airflow from your lungs. COPD can lead to difficulty breathing, mucus buildup, and coughing. COPD is usually caused by prolonged exposure to irritating gases or particulate matter like smoke from a cigarette and can lead to an increased risk of heart disease or lung cancer.

Luis Salazar, MD

Christina N. Oliveros, RN

Ashley Vazquez

Ashley Vazquez, MA, CCM


Diabetes occurs when a patient’s blood sugar levels are high. This can cause unexplained weight loss, increased thirst, fatigue, frequent urination, and other symptoms which can be difficult to manage.

Type 1 diabetes means that the body cannot use sugar effectively. Patients with Type 2 diabetes do not process sugar as well as they should. A change in diet, exercise, and sometimes medicines such as insulin is recommended for treating diabetes.

Jadirh Gonzalez

Jadirh González, CCM Coordinator

High Cholesterol (Lipid Abnormality)

Cholesterol is a thick, wax-like substance that forms in the blood. Although necessary for building your body’s cells, too much cholesterol can lead to fatty build-ups in blood vessels, making your body’s ability to pump blood much harder. If left untreated, high cholesterol can lead to high blood pressure, heart disease, risk of a heart attack, and increased risk of a stroke.

Because there are no symptoms to warn of high cholesterol, a blood test is the only way to detect its presence. We recommend that a person receive a blood test from their primary physician.


High Triglycerides

Triglycerides are a type of fat that is found in blood. They are also called lipids and help maintain energy between meals. If you eat or drink more calories than you burn off, you may have a high level of triglycerides which increases your risk of heart disease and stroke. Treatment options include maintaining a healthy diet, weight loss, frequent exercise, and limited alcohol consumption.



Hypothyroidism occurs when the thyroid gland doesn’t produce the necessary hormones. Over time this can cause health problems like heart disease, joint pain, and obesity. Symptoms include weight gain, fatigue, muscle weakness, thinning hair, painful joints or muscles, slowed heart rate, and constipation.

To diagnose hypothyroidism, a thyroid function test can be performed at Provida Family Medicine, and your provider can discuss an individualized treatment plan that’s right for you.



Hypertension, also known as high blood pressure, occurs when the force of the blood against artery walls is too high. If left untreated, hypertension can lead to heart disease and other health issues.

Some symptoms include headaches, nosebleeds, or shortness of breath, but every patient is not guaranteed to experience these symptoms. Some patients with severely high blood pressure may not experience any symptoms.

The best way to know if you have high blood pressure is to come in for yearly health checks where a blood pressure test can be performed, and your health can be monitored and tracked over time.



Obesity is an excessive amount of body fat caused by: inherited factors, environmental factors, and personal diet and exercise choices. Obesity can increase your risk of heart disease, high blood pressure, diabetes, and cancer.


Peripheral Vascular Disease

Peripheral vascular disease is a chronic disease that affects a person’s blood vessels as narrow blood vessels reduce blood flow in the limbs.

Peripheral vascular disease can signal that a patient has fatty deposits and calcium building up within the walls of the arteries. As patients age, there is a higher risk that they will develop peripheral vascular disease. Other factors that may increase the risk of this illness include previous limb injuries, smoking, and diabetes. A patient may also experience leg pain, particularly when walking. Exercise and lifestyle changes to increase blood flow are recommended. In some cases, surgery or medication will also be recommended. Speaking with your provider to assess what treatment is best for you is best.