Care Management and Remote Monitoring

Care Management and Remote Monitoring

- Sisselman Medical Group -

Chronic/ Complex Care Management

Chronic/Complex Care Management (CCM) is a program designed for patients with two or more chronic conditions expected to last 12 months or more or place them at significant risk of death, acute exacerbation/decompensation, or functional decline. The most common chronic conditions we support are: HTN, Diabetes, CHF, Hyperlipidemia, COPD, Obesity, Depression, Cancer, Osteoarthritis and Dementia.


CCM services provide:

  • Comprehensive assessments and person-centered care plans
  • Patient education (disease process, medication, community resources)
  • Preventive service reminders
  • Transition of care management
  • RN continuity for optimal patient and caregiver engagement and experience
  • Care coordination and information exchange with Specialists and other providers
  • Support using motivational interviewing techniques to affect lasting health behavior change
  • 24/7 patient access to care and health information
  • Provide patients and or caregivers with copy of the care plan
  • Comprehensive billing reports for practice
  • Patient advocacy


Other Health Coach Activities/Coordination/Referrals:

  • Prescription Assistance, Medication Assistance Programs and Co-Pay Assistance Programs
  • Transportation coordination
  • Advance Care Planning
  • Community/SDOH resources -good insecurity, utility assistance, housing assistance
  • PHQ9 Assessments
  • Dietician, specialists, nutritional Programs
  • Medicaid Assistance/Social Worker
  • Senior well-being and senior day program


While CCM services are covered by many insurance plans, some plans may require a small co-pay.

Remote Patient Monitoring

Remote patient monitoring is a program designed for Medicare and Medicare Advantage patients. Sisselman Medical Group provides our Medicare patients with a stress-free way to manage your health in “real-time”.


Patients managing chronic conditions like high blood pressure, diabetes, congestive heart failure and COPD should reach out to your provider to see if you are eligible for this program and obtain a referral from your healthcare provider.


Remote patient monitoring provides a view into the status of your day-to-day health, which offers your healthcare provider a fast and efficient way to make necessary adjustments in your plan of care to keep you healthy and prevent inconvenient and costly emergency room and hospitalizations in between your in-person office visits.


With easy-to-use technology, Sisselman Medical Group provides a method for self-monitoring and sharing of important health data with your healthcare provider such as: blood pressure, blood glucose, weight, and oxygen levels conveniently and from the comfort of your home.


You will experience peace of mind knowing the Sisselman Medical Group team of healthcare professionals is looking out for you. You’ll receive:


Continuous Support

  • You can easily reach out to your personal health coach for support when you need it.
  • Your personal health coach regularly monitors and communicates with your medical provider about out-of-range health data readings for early intervention and treatment.


Better Health Together

  • You will receive monthly outreach calls and as you need messaging with our Health Coaches to provide you with education and guidance in understanding your health data.


What other Sisselman Medical Group patients like you are saying about the program:

  • “This program helps me cut through the hassle of managing my health on a day-to-day basis. It makes me feel like I'm not alone anymore.”
  • “Having someone to ask questions to and having someone hold me accountable for things on a daily basis has been invaluable.”


Are you ready to live your best life? If so, please reach out to your provider today!

Our Team

Cynthia Marceaux, RN | Sisselman Medical Group

Cynthia Marceaux, RN

Cynthia is a registered nurse with diverse experiences in providing and training quality care management using clinical expertise in chronic conditions, medication management, and post hospital in-home care. She desires to be a part of programs that advance knowledge and simplify the healthcare processes and systems for providers and patients.

 

As you get to know her, you will learn quickly that she is very passionate and detail oriented and is very excited to join our team, as we move into the future.

 

Cynthia comes to us from the New Orleans area and currently resides in the small, quaint town of Ponchatoula, Louisiana.


She is the very proud grandmother of 3 ½ year old fraternal twins, Chloe and William, and also has a precious Australian Miniature Labradoodle named, Celley Pearl, who can often be seen in her video calls. 

Katelyn Pedro, RN | Sisselman Medical Group

Katelyn Pedro, RN

Katelyn is a Registered Nurse with experience in diverse healthcare settings, including the emergency room, operating room, women’s health, public health, and telehealth, with a focus on remote patient monitoring and chronic care management. Since earning her nursing credentials in 2006, she has developed a broad skill set in critical care, patient assessment, care coordination, and chronic disease management.


Outside of her nursing career, Katelyn enjoys snowboarding, hiking, paddle boarding, and reading. She is committed to providing patient-centered care and fostering strong, empathetic relationships with patients and their families, all while maintaining a focus on improving overall health and well-being.

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