Chronic Care Management Services — Heart of An Angel Nursing Solutions

Nurse Tina
Apr 6
3 min read

Bridging the Gap Between Office Visits

Chronic conditions require more than a few minutes in a doctor's office. Heart of An Angel Nursing Solutions provides dedicated Chronic Care Management (CCM) services — delivering nurse-led support, personalized care planning, and consistent patient engagement between physician visits. Our mission is simple: keep patients healthier, reduce avoidable hospitalizations, and give physicians the peace of mind that their patients are in good hands 24/7.

For Physicians & Healthcare Providers

Extend Your Reach. Strengthen Patient Outcomes.

As a physician, your time is your most valuable resource. Heart of An Angel Nursing Solutions acts as an extension of your care team — providing the continuous, hands-on patient support that today's chronic care landscape demands. We partner with your practice to ensure patients with two or more chronic conditions receive the structured attention they need between office visits.

Here's how we support your practice:

Monthly Nurse-Led Check-In Calls — Regular structured phone or telehealth visits keep patients engaged and on track with their care goals.
Individualized Care Plan Creation & Updates — We develop and maintain comprehensive, patient-centered care plans aligned with your clinical recommendations.
Medication Adherence & Reminders — Our nurses monitor and encourage medication compliance, catching gaps before they become emergencies.
Progress Reports Delivered to Your Office — You stay informed with clear, concise updates on your patient's health status, symptoms, and any concerns that arise.
Care Coordination & Referral Support — We help navigate specialist referrals, follow-up appointments, and transitions of care to eliminate gaps in treatment.
24/7 Patient Access to a Care Team — Patients can reach our nurses with questions or concerns at any time, reducing unnecessary ER visits and after-hours calls to your office.

CCM is a Medicare-reimbursable service (CPT codes 99490, 99439, 99487, 99489) — meaning that by referring your eligible patients to our program, you help them access a valuable benefit at little or no cost to them, while improving your practice's quality metrics.

Ready to refer a patient? Contact us at admin@heartoaa.com or call 1.877.423.2420 to discuss a partnership with your practice.

For Patients

You Deserve Support Every Single Day — Not Just During Appointments.

Living with a chronic condition like diabetes, heart disease, hypertension, COPD, or any long-term health issue can feel overwhelming — especially between doctor visits. Heart of An Angel Nursing Solutions is here to walk alongside you every step of the way. Our compassionate registered nurses become your personal health advocate, ensuring you always have someone in your corner.

When you enroll in our Chronic Care Management program, you receive:

A Personal Care Plan — A customized roadmap for managing your specific health conditions, goals, and daily needs.
Regular Check-In Calls — Monthly calls with a caring nurse who listens, tracks your progress, and answers your health questions.
Medication Support — Reminders and education to help you stay on top of your medications safely and consistently.
Health Education & Lifestyle Guidance — We help you understand your conditions and make empowered, informed decisions about your health.
Appointment Coordination — We help schedule follow-ups, specialist visits, and make sure you never fall through the cracks of the healthcare system.
Someone Who Truly Cares — Our nurses bring the heart of an angel to everything they do. You're not a case number — you're family.

The best part? If you have Medicare, CCM services may be covered at little or no cost to you. Ask your doctor if you qualify, or contact us directly to find out.

How Our CCM Program Works

Enrollment — Your doctor refers you, or you contact us directly to get started.
Initial Assessment — We conduct a thorough health assessment and build your personalized care plan.
Ongoing Monthly Support — Your dedicated nurse checks in regularly, tracks progress, and addresses concerns.
Physician Reporting — We communicate directly with your doctor, keeping your entire care team aligned.
Continuous Improvement — Care plans evolve with your needs, ensuring you always receive the right level of support.

Take the Next Step Today

Whether you're a physician looking to strengthen patient outcomes or a patient ready to take control of your health, we are here for you. Heart of An Angel Nursing Solutions is committed to delivering compassionate, high-quality chronic care support that makes a real difference.

📞 Call us: 1.877.423.2420 | ✉️ Email: admin@heartoaa.com | 🌐 Visit: heartoaa.com

Heart of An Angel Nursing Solutions — Caring for your patients like family, every day.