Chronic Care Management
Ongoing care coordination for eligible patients managing two or more chronic conditions. KSM helps patients stay engaged with their care plan, navigate barriers, coordinate next steps, and maintain continuity between visits.
Services
Care Management That Extends Beyond the Visit.
KSM SupportLink works alongside outpatient practices to provide structured care management, patient navigation, and ongoing coordination between visits.
Care Management Programs
Four Ways to Extend Patient Support
KSM supports practices across four care management and navigation programs, allowing support to be aligned with the needs of the patient and the participating practice.
Principal Care Management
Focused care management for eligible patients with one serious or complex chronic condition. Support centers on the needs, barriers, and follow-through associated with that principal condition.
Community Health Integration
Support for patients whose medical care is affected by social or practical barriers. KSM helps patients navigate challenges such as transportation, food access, housing concerns, financial barriers, and community resources.
Principal Illness Navigation
Personalized navigation for eligible patients facing a serious, high-risk illness. KSM helps patients navigate appointments, specialists, resources, and the practical demands of a complex care journey.
What KSM Does
Practical Support Across the Care Journey
The exact support provided depends on the patient's needs and the applicable care management program.
Patient-Centered Coordination
KSM helps bridge the space between the care established by the practice and the patient's ability to navigate and follow through outside the clinic.
As needs change, support can be adjusted in collaboration with the participating practice.
Assessment & Care Planning
Identifying patient priorities, barriers, support needs, and appropriate coordination goals.
Patient Outreach & Follow-Up
Maintaining regular contact and helping patients stay engaged between provider visits.
Referral & Appointment Navigation
Helping patients navigate referrals, appointments, specialists, transportation, and logistical next steps.
Community Resource Navigation
Connecting patients with appropriate social and community resources when barriers to care are identified.
Medication Adherence Support
Identifying practical adherence barriers, supporting follow-through, and routing medication-related concerns to the clinical team.
Preventive Care Follow-Up
Supporting reminders and follow-through for provider-identified preventive care needs and care gaps.
Psychosocial Support
Providing appropriate supportive engagement and helping connect patients with additional resources when needed.
Documentation & Practice Updates
Documenting patient contacts, coordination activities, progress, barriers, and relevant communications.
The Process
From Referral to Ongoing Support
KSM integrates into the practice's workflow through a structured coordination process.
01
Practice Referral
The practice identifies an appropriate patient, completes applicable enrollment or consent requirements, and sends the referral to KSM.
02
Patient Outreach
KSM contacts the patient, introduces the support process, and begins engagement.
03
Assessment & Plan
Patient needs, priorities, and barriers are identified and an individualized coordination plan is established.
04
Ongoing Support
KSM provides the applicable care management, navigation, follow-up, and resource coordination services.
05
Practice Communication
Activities are documented and relevant progress, unresolved barriers, and concerns are communicated back to the practice.
Connected to the Practice
Support That Doesn't Operate in a Silo
Care management works best when the practice remains informed. KSM keeps coordination activities organized and communicates relevant information back to the participating team.
Documented Activity
Patient contacts, services provided, coordination activities, progress, and time are documented through the agreed workflow.
Barrier Tracking
Unresolved needs and barriers are tracked so they can continue to be addressed rather than being lost between encounters.
Clinical Escalation
Questions or concerns requiring medical evaluation, interpretation, or clinical decision-making are routed to the appropriate practice team.
Care Management With Clear Clinical Boundaries.
KSM provides coordination, navigation, and patient support. Diagnosis, prescribing, treatment changes, and other medical decisions remain with the patient's physician and appropriate clinical team.
Explore a Partnership With KSM SupportLink.
Tell us about your current care management needs and we can discuss how KSM may integrate into your practice's workflow.