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TEST - DRAFT CHS 2025 Annual Report-3

Health & Hope is a newsletter designed to educate and inspire Western Montanans on life-saving procedures, community events and services to keep you and your family healthy.

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For Medicare patients living with two or more chronic conditions, managing health can be overwhelming. The Chronic Care Management (CCM) program, established by the Centers for Medicare & Medicaid Services (CMS), strengthens care coordination and provides structured support between primary care visits. Covenant Medical Group's CCM program continues to grow in both reach and impact, now serving approximately 1,300 patients each month. This steady growth reflects the program's success in closing care gaps, improving communication, and strengthening continuity between visits. Once enrolled, each patient is assigned a dedicated personal care coordinator. Following a comprehensive intake assessment, the CCM team develops an individualized care plan with clear goals and action steps tailored to each patient's chronic conditions. Chronic Care Management Services Include: Monthly telephone check-ins between PCP visits Medication review and reconciliation Education on chronic disease management Support for new symptoms or diagnoses Direct access to a care coordinator 24/7 nurse line for urgent after-hours needs The program supports patients managing conditions such as high blood pressure, diabetes, high cholesterol, asthma, arthritis, atrial fibrillation, cancer, COPD, depression, anxiety, congestive heart failure, and osteoporosis. Through proactive outreach and intentional care coordination, Chronic Care Management reinforces Covenant Medical Group's commitment to improving patient satisfaction and reducing unnecessary emergency department utilization. By identifying concerns early, ensuring medication adherence, and providing timely access to clinical guidance, the program helps patients avoid preventable complications while feeling cared for with purpose and personalization. Patients consistently report feeling more confident in managing their conditions because they know a dedicated team is actively monitoring their progress and walking alongside them. Medicare patients with two or more chronic conditions are encouraged to ask their provider for a referral. Chronic Care Management Coordinated Care. Measurable Impact. Covenant Medical Group continues to expand access to preventive care and hypertension management across our communities. Through coordinated outreach and intentional follow-up, thousands of patients received structured blood pressure monitoring, education, and personalized support. A Free Walk-In Blood Pressure Check Clinic removes barriers to early detection and intervention, while a new Social Worker pilot — now billable in two primary care locations — strengthens integration of clinical and social services. Patients receiving at-home blood pressure cuffs report greater confidence and accountability in managing their health between visits. The Result: Stronger engagement. Earlier intervention. Improved hypertension control — and meaningful progress toward reducing avoidable complications. Hypertension Care in Action Expanding Access, Improving Control, Preventing Complications 3,314 Patients Served 325 Referrals to Social Work & Diabetic Education Coordinated Care Lives for Healthier COVENANT HEALTH 2025 ANNUAL REPORT 1

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