Continual Access to Care Management Services — Chronic care managers provide patients with round-the-clock access to healthcare providers in order to address urgent care needs. This does not mean that every practitioner on the care team must be available at all times, but that there is access to a healthcare professional that is able to address their needs in a timely manner, regardless of the time of day or night. Continuity of Care — Continuity of care means that a patient is able to see the same physician on their care team for routine appointments. This allows patients to have a certain level of consistency of care. Care Management — Chronic care managers are actively involved in patients’ care, including ensuring patients receive the recommended care services, such as preventative care. They also oversee the patients’ medication management. Patient-Centered Care Plan — Essential to the highest quality care, chronic care managers create a treatment plan that is tailored to their patients’ specific needs, choices and values. Cognitive ability and environmental factors are taken into consideration, as they may affect a patient’s ability to implement certain components of a care plan. Help with Care Transitions — Care transitions occur when care shifts between providers or settings, such as being discharged from a hospital.