top of page



Doctor's Desk

A Chronic Care Management Program 

Untitled design (20).png

Enrollment in
Southeast Texas

Give us a call at 1-833-698-6825 EXT. 1 to schedule a visit with a provider today.

For Virtual / Partner Practices

Please visit our concierge company website at

Your Medical Home is a healthcare company comprised of doctors, nurse practitioners, nurses and care staff who are dedicated to improving people’s lives by changing the way the world experiences healthcare by bringing Health Care to you. Our Concierge Wellness program is designed to deliver comprehensive, compassionate medical wellness services to adults. It enables the doctor to extend their care outside the office. We understand that navigating the healthcare system is complicated and accessing the type of care you need, when you need it, is even more complex. This is why we provide each patient with a nurse who checks in regularly to assess and coordinate additional care and therapy as needed. We protect your patient privacy while prioritizing your healthcare needs so you can focus on living well.


Our Services

On-Site Nurse Practitioner for Large Senior Housing Complexes 
Chronic Care Management
Yearly Wellness Visits
Sick Visits 
Flu Shots
Transportation Coordination
Case Management
IV Hydration
Transitional Care Management
On-Site Labs
Medication Management
Life Coaching
Vital Monitoring
Doctor and Patient

For Patients


For Doctors Office

Senior Couple

For Senior Housing

Construction Worker_edited.jpg

For Industry

Qualifying Chronic Conditions

Patient must have two qualifying chronic conditions to be enrolled in this program. (Chronic Condition List Subject to Change)
Heart Failure
Chronic Kidney Disease
Bipolar Disorder
Heart Disease
Chronic Obstructive Pulmonary Disease 
Atrial Fibrillation
Ischemic Heart Disease

Acute Myocardial infarction
Major Depressive Disorder

Alzheimer's Disease
Autistic Spect
rum Disorders
Chronic Weight Gain or Loss 


Practice or Senior Living Facility Requests:


Improves visibility between visits

Caring for at-risk populations takes time and attention. Given many competing priorities, physicians have limited time and visibility into what is happening in between visits. Our care team can help your practice or facility manage patient care during that time.

Empowers patients and providers

YMH Chronic Care Management brings clinical expertise and patient-centered approach to drive adherence to provider care plans. Improved coordination of care, increased patient engagement and seamless workflow integration drive sustainable outcomes for senior living facilities and medical practices.

The power of partnership

With over 20 years of experience, YMH understands the importance of partnering with providers and senior housing. Serving as an extension of your practice or facility, we help ensure care coordination is focused at the patient level, taking the extra time needed with each patient in between visits.

  • What is CCM
    CCM is a chronic care management program that helps residents with two or more chronic conditions manage their health with a personal case manager.
  • How Often is a Provider Available
    Our CCM program has a 24/7 line for all patient questions and evaluations.
  • What is chronic care management, and how does it differ from traditional healthcare services?
    Chronic care management is a comprehensive and coordinated approach to managing the care of patients with chronic conditions. It differs from traditional healthcare services by emphasizing proactive management, continuous support, and personalized care plans tailored to the specific needs of patients with long-term health issues.
  • Who is eligible for chronic care management services?
    Patients with multiple (two or more) chronic conditions expected to last at least 12 months, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, are typically eligible for chronic care management services.
  • What are the benefits of participating in a chronic care management program?
    Benefits may include improved disease management, enhanced quality of life, reduced hospitalizations, better medication adherence, increased access to care, and ongoing support from a dedicated care team.
  • How does a chronic care management program work, and what services are typically included?
    CCM programs involve regular care coordination, medication management, 24/7 access to healthcare professionals, comprehensive care plans, and assistance with transitions of care, among other services.
  • What is the role of a care coordinator in a chronic care management program, and how can they help me?
    Care coordinators help patients navigate the healthcare system, manage appointments, understand treatment plans, provide education about their conditions, and ensure effective communication between the patient and their healthcare team.
  • Will my insurance cover the costs of chronic care management services?
    Many insurance plans, including Medicare, offer coverage for chronic care management services. However, coverage specifics may vary, so it's essential to check with your insurance provider.
  • Can I still see my primary care physician or specialist while participating in a chronic care management program?
    Yes, patients can continue to see their primary care physician and specialists while participating in a chronic care management program. The program is designed to complement the care provided by these healthcare professionals. You will be encouraged to see your primary care physician.
  • How often will I need to communicate with my care team, and through what means (e.g., phone, email, in-person visits)?
    Communication frequency may vary based on individual needs, but it often involves regular phone calls and electronic communications to monitor the patient's health status, provide guidance, and address any concerns or questions.
  • How does the chronic care management program ensure the privacy and security of my health information?
    CCM programs adhere to strict privacy regulations outlined by HIPAA (Health Insurance Portability and Accountability Act) to ensure the confidentiality and security of patients' health information.
  • How can a chronic care management (CCM) program be beneficial to a senior housing facility?
    Improved Health Outcomes: By implementing a CCM program, senior housing facilities can ensure that residents with chronic conditions receive ongoing monitoring, timely interventions, and personalized care plans, leading to improved health outcomes and a higher quality of life. Reduced Hospital Readmissions: With regular monitoring and proactive care, the CCM program can help prevent health complications that might otherwise lead to hospital readmissions. This not only improves the residents' well-being but also reduces the financial burden on the facility. Better Medication Management: CCM programs can assist in organizing and managing medication schedules for residents with chronic illnesses, minimizing the risk of medication errors and adverse drug interactions, which are particularly crucial in senior populations.
  • Wound Care / Who Qualifies?
    Once your community is enrolled in our Concierge Wellness program each patient that qualifies for CCM will be evaluated for all wound care treatments. This treatments are done on-site or in one of our local offices.
  • How do I schedule on-site flu shots for my community
    Your case manager will be reaching out to you in July/August to schedule on-site flu shots for all CCM residents and staff in your community that qualify. -Flu Shots are giving between September - March -65+ Flu Shots are avalible for those who qualify
bottom of page