Enhanced Care Services

    Transforming Patient Care Experience

    At Commonwealth Primary Care ACO, we prioritize proactive health management. Our Enhanced Care Services tackle chronic conditions while focusing on the individual as a whole. By merging physical, mental, and emotional health, we offer a well-rounded approach that empowers patients in their health journeys. Learn how we connect you with tailored resources, specialists, and support systems, ensuring everyone has the tools to thrive.

    Find a Commonwealth Primary Care ACO Provider

    Chronic Care Management (CCM)

    Living with multiple chronic conditions can feel overwhelming, but you don’t have to manage it alone. Our Chronic Care Management program provides patients with ongoing support between office visits to help stay on top of their health.

    Through CCM, you’ll receive:

    • Personalized care coordination with your primary care team

    • Regular check-ins to monitor your progress and answer questions

    • Medication management support to help you take prescriptions safely and correctly

    • 24/7 access to health information through your care team and patient portal

    • Peace of mind knowing your doctor is closely involved in your ongoing care

    This program is designed to make it easier for you to manage conditions like diabetes, heart disease, high blood pressure, COPD, and others — helping you stay healthier and avoid unnecessary hospital visits.

    Transitional Care Management (TCM)

    Coming home after a hospital stay is an important step in your recovery — but it can also be overwhelming. Our Transitional Care Management program is designed to make that transition smoother, safer, and more supportive.

    With TCM, we:

    • Follow up quickly after your discharge to check on your health and answer questions

    • Coordinate with your hospital and specialists to make sure your care plan is clear

    • Review your medications so you know exactly what to take and how to take it

    • Schedule timely appointments with your primary care provider

    • Provide support and guidance to reduce the chance of needing to return to the hospital

    Our goal is to help you recover with confidence, avoid complications, and get back to your routine as smoothly as possible.

    Meet our Care Coordination Team

    Debbie Parker LPN
    Chronic Care Management Supervisior
    Debbie is our Chronic Care Management Supervisor with over 27 years of nursing experience, bringing leadership, expertise, and a dedication to enhancing patient care and team collaboration.
    Tanya Platt LPN
    Chronic Care Coordinator
    Tanya is our Chronic Care Nurse with 19 years of experience, bringing compassion, expertise, and a strong commitment to supporting patients and their families.
    Jaime Tucker LPN
    Chronic Care Coordinator
    Jamie Tucker LPN
    Chronic Care Coordinator
    Kari Upton LPN
    Chronic Care Coordinator
    Sherri Colgan LPN
    Transitional Care Coordinator
    Erica Thomas LPN
    Transitional Care Coordinator
    Erica is our Transitional Care Nurse with over seven years of experience, dedicated to supporting patients through smooth transitions from hospital to home with compassion and care.
    Jessica Brooks
    Transitional Care Patient Support Specialist

    Together on the Path to Better Health

    The Impact of Care Coordination…

    I get efficient and fast responses to my questions. Feels like the doctor's staff actually care for their clients' well-being.
    CCM Patient
    CCM Patient
    The reminders make me take a look at how I really feel.
    CCM Patient
    CCM Patient
    The most helpful thing is knowing there is someone there if I need something that might not require an appointment with my doctor. Also makes me feel that someone is looking out for me.
    CCM Patient
    CCM Patient
    I like the fact that I am being looked after and treated as an adult not preached at!
    CCM Patient
    CCM Patient
    We like texting better than phone calls for making appointments.
    CCM Patient
    CCM Patient
    Good prompts to remind me to follow up on health care needs
    CCM Patient
    CCM Patient
    The messages are encouraging, uplifting, personal and good advice. Your messages are helpful in reminding me about prescription refills and you return messages in timely manner.
    CCM Patient
    CCM Patient
    Most helpful is your role as liaison between me and my Primary Care for prescriptions, appointments, etc.
    CCM Patient
    CCM Patient
    Sometimes I have a quick question for you and you respond quickly. Calling the office is challenging so this service is awesome.
    CCM Patient
    CCM Patient
    I appreciate you always checking in on me! Thank you for that! 💗
    CCM Patient
    CCM Patient
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