Chronic Care Management

Are you or a loved one facing the challenges of chronic health conditions? Monadnock Community Hospital’s Runways program is here to provide you with compassionate, personalized support.

Our Mission and Vision

At Monadnock Community Hospital our mission is clear: Improve the health and well-being of our community by providing accessible, high-quality care. This program is not just about managing conditions. It is about creating a better life for you.

Who can benefit from this program?

Anyone in our community on Medicare who suffers from two or more chronic conditions and is currently being treated by a primary care provider at Monadnock Health Partners. The program is especially useful for those who have difficulty managing their care on their own, or who could use extra assistance navigating the healthcare system.

What can you expect from Runways?

Participants of the Runways program receive regular phone calls from a personal care navigator. Your care navigator will help you address issues before they turn into larger problems. Because of this, monthly care management calls may reduce total cost of care for people suffering from chronic diseases, while improving their overall wellness. Here is what you can expect:
  • During your first call, you and your care navigator will review the care plan and goals that you have set with your primary care provider.

  • At least once a month, your care navigator will call to check-in. You will discuss your care plan and talk about the progress you have made toward your goals.

  • Between check-ins, you can call your care navigator at any time between 8 a.m. and 6 p.m. Monday-Friday. If you leave a message they will return your call within twenty-four hours.

Frequently Asked Questions

What is the Runways Chronic Care Management Program?

Our program is a specialized healthcare initiative designed to support individuals with chronic conditions in the Monadnock region. We provide personalized care and coordination to enhance quality of life for those facing long-term health challenges.

How will your care navigator assist you?

Your care navigator can help you with a wide range of services related to your health. This can include:

  • Facilitating communication between your specialist care teams and your primary care office

  • Researching problems with prescriptions (lost, incorrect, not filled) and verify that you are taking your medications as prescribed

  • Reviewing your physician-recommended diet and exercise plan

  • Offering resources for addressing depression and anxiety

  • Assisting with transportation, food, or housing concerns

  • Providing a friendly and encouraging voice to look forward to every month

Who is eligible?

If you are a Medicare subscriber who is currently managing more than one chronic condition, you may be eligible for this program. In order to qualify, you must meet the following criteria:

  • Subscribe to a Medicare plan

  • Have two or more chronic conditions expected to last more than 12 months

  • Be an established patient with a Monadnock Health Partners primary care practice and have been seen within the last 12 months

How does the program work?

Our dedicated care team works closely with patients, offering support through regular monthly check-in calls, personalized care plans, and access to resources. We aim to empower individuals to take control of their health and make informed decisions.
How can I enroll or refer someone to the program?
There are several ways you can reach out to enroll:

  • Call our enrollment team at 603-277-3364. They will answer your questions, help you enroll and schedule your first call with one of our Care Navigators.

  • Consult with your primary care provider. If the program is the right fit for you they can refer you.

  • If you are eligible, you may also receive an outreach call or letter from our program.

Is there a fee for this service?

Often times, primary insurance carriers do not cover the full cost of these services. In that case, members would be responsible for a small monthly copay. A secondary or supplemental insurance may cover this copay. You can discuss any cost concerns with the enrollment team.

Your Journey to Better Health Begins Here

We are excited to embark on this journey with you. Your health and well-being are our top priorities. Join Runways Chronic Care Management Program and let’s take the first step towards a healthier, more vibrant life together.
To learn more about Chronic Care Management, call our enrollment team at 603-277-3364. They will answer your questions, help you enroll and schedule your first call with one of our Care Navigators.