Whole-person chronic care management built around the real needs of the patient.
BloomCare’s CCM program goes beyond traditional monthly check-ins by capturing the full picture of a patient’s health, lifestyle, risks, barriers, and care needs.
Designed for patients living with multiple chronic conditions who need consistent, RN-led support between provider visits. Our model focuses on the whole patient, evaluate clinical needs, medication adherence, symptoms, lifestyle, nutrition, mobility, social barriers, and disease progression metrics over time.
What Makes BloomCare CCM Different
Traditional CCM programs often focus on monthly outreach and basic care plan documentation. BloomCare’s CCM model is designed to be deeper, more proactive, and more connected. Our Registered Nurses and care team members look across the patient’s entire health journey to identify gaps, risks, and opportunities for earlier intervention.
- RN-led longitudinal care coordination
- Whole-person patient assessments
- Social drivers of health screening
- Medication adherence and refill barrier review
- Disease prevention and disease progression monitoring
- Diet, nutrition, lifestyle, and activity support
- Mobility and functional risk awareness
- Caregiver needs identification when appropriate
- Daily automated check-ins based on diagnoses and risk level
- Escalation pathways for acute concerns
- Integration with BloomAccess™ for same-day virtual visits, labs, and imaging through partnered vendors when clinically appropriate
Who CCM Supports
BloomCare CCM is designed for patients with two or more chronic conditions who benefit from ongoing care coordination and structured follow-up.
- Diabetes & Hypertension
- Congestive heart failure & COPD
- Chronic kidney disease & Coronary artery disease
- Obesity, depression, and anxiety with chronic illness
- Polypharmacy & functional decline or fall risk
- Frequent hospital or emergency department utilization
- Social barriers impacting care adherence
What BloomCare Captures
BloomCare captures the patient’s health from multiple angles so providers have better visibility into risks, barriers, and care opportunities.
- Chronic condition status & worsen symptoms
- Medication adherence, refill issues, and side effects
- Appointment completion & health literacy needs
- Diet, nutrition patterns, activity, and mobility
- Fall risk concerns & behavioral health needs
- Caregiver involvement & structural health gaps
- Transportation, food, housing, and financial barriers
Daily Automated Check-Ins
Heart Failure
Weight, swelling, shortness of breath, and medication adherence check-ins.
Diabetes
Glucose, diet, medication timing, and related symptom check-ins.
COPD
Breathing parameters, oxygen saturation tracking, inhaler use, and exacerbation checks.
Hypertension
Blood pressure logs, headache, dizziness, and medication adherence check-ins.
Escalation & BloomAccess™
When acute concerns are identified, BloomCare follows structured escalation workflows. Depending on the situation and available partnerships, patients may be routed through BloomAccess™ for same-day virtual provider visits, labs, imaging, or additional support through partnered vendors.
Important Note: BloomAccess™ is designed to support timely access and escalation. Emergency symptoms are directed to emergency services according to clinical protocols.
Supported CCM Outcomes
- Improved patient engagement & satisfaction
- Better care plan follow-through & tracking
- Earlier identification of dynamic risks
- Improved medication adherence metrics
- Reduced avoidable hospital utilization
- Stronger provider panel visibility
- Better systematic chronic disease support
GENERAL DISCLAIMER: BloomCare supports provider-led care coordination, documentation workflows, patient engagement, monitoring, and escalation support. Services are subject to payer rules, patient eligibility, medical necessity, provider documentation, and applicable regulatory requirements. BloomCare does not guarantee reimbursement or clinical outcomes.