Try Chronic Care Management with 16S Health Today

Your Practice Partners in Optimizing your Patient's Health

Providing and Streamlining CCM, PCM, and RPM Services to Improve Health Outcomes and Increase Practice Revenue

4,000+

Patients per Month

Patient-Centered Care

We prioritize the needs and well-being of our patients, ensuring they receive personalized, comprehensive care that empowers them to take control of their health journey.

Collaboration and Communication

We believe in fostering strong partnerships with healthcare providers, patients, and our team. Open communication and collaboration enhance care coordination and improve health outcomes.

Innovation in Healthcare

We embrace innovation and leverage the latest technology and evidence-based practices to improve care delivery and patient outcomes, ensuring our services remain effective and efficient

About Chronic Care Management (CCM)

What is CCM?

Why is CCM important?

Why does Medicare encourage CCM?

Why do patients want to enroll?

Chronic Care Management (CCM) is a service offered to Medicare Beneficiaries with 2 or more chronic conditions It includes a comprehensive care plan with all of the patient’s health problems and goals, other providers, medications, community services available, and other information about their health. Providers help with medication management, provide access for urgent care needs, support in transitions of care, review medications and how to take them, and help with other chronic care needs.

What is CCM?

Why is CCM important?

Why does Medicare encourage CCM?

Why do patients want to enroll?

What is CCM?

Why is CCM important?

Why does Medicare encourage CCM?

Why do patients want to enroll?

What is CCM?

Why is CCM important?

Why does Medicare encourage CCM?

Why do patients want to enroll?

We Provide and Streamline CCM/PCM/RPM Services

The concurrent implementation of RPM and CCM/PCM is a key driver for a sustainable value-based care model that improves the quality of care and health outcomes for patients while still lowering the overall cost of healthcare.

Improved Care Coordination

Supporting Patient Compliance

Helping Patients Feel More Connected

Our Team

Meet the 16S Health Team

Your Dedicated Partners in Health and Wellness

Gastroenterology Associates of Central Georgia, Associate Professor of Medicine and Surgery at Mercer University School of Medicine

Shahriar Sedghi, M.D. AGAF

Clinical Pharmacist, Value Based Care Specialist, Student Preceptor at the University of Pittsburgh and Duquesne University

Amanda Rae Baum, PharmD.

Associate Professor Professional Studies in Dietetics, Program Director University of Nebraska

Heather Rasmussen, Ph.D., RD

Department of Internal Medicine, Division of Infectious Diseases Director of Genomics and Microbiome Core Facility, Rush Medical College

Stefan Green, Ph.D.

Director of Whistler Center for Carbohydrate Research Professor at Purdue University, Food Science

Bruce Hamaker, Ph.D.

Director of Center for Integrated Microbiome & Chronobiology Research at Rush University

Ali Keshavarzian , MD, FRCP, FACP, MACG,AGAF

Gastroenterology Associates of Central Georgia, Associate Professor of Medicine and Surgery at Mercer University School of Medicine

Shahriar Sedghi, M.D. AGAF

Clinical Pharmacist, Value Based Care Specialist, Student Preceptor at the University of Pittsburgh and Duquesne University

Amanda Rae Baum, PharmD.

Associate Professor Professional Studies in Dietetics, Program Director University of Nebraska

Heather Rasmussen, Ph.D., RD

Department of Internal Medicine, Division of Infectious Diseases Director of Genomics and Microbiome Core Facility, Rush Medical College

Stefan Green, Ph.D.

Director of Whistler Center for Carbohydrate Research Professor at Purdue University, Food Science

Bruce Hamaker, Ph.D.

Director of Center for Integrated Microbiome & Chronobiology Research at Rush University

Ali Keshavarzian , MD, FRCP, FACP, MACG,AGAF

Gastroenterology Associates of Central Georgia, Associate Professor of Medicine and Surgery at Mercer University School of Medicine

Shahriar Sedghi, M.D. AGAF

Clinical Pharmacist, Value Based Care Specialist, Student Preceptor at the University of Pittsburgh and Duquesne University

Amanda Rae Baum, PharmD.

Associate Professor Professional Studies in Dietetics, Program Director University of Nebraska

Heather Rasmussen, Ph.D., RD

Department of Internal Medicine, Division of Infectious Diseases Director of Genomics and Microbiome Core Facility, Rush Medical College

Stefan Green, Ph.D.

Director of Whistler Center for Carbohydrate Research Professor at Purdue University, Food Science

Bruce Hamaker, Ph.D.

Director of Center for Integrated Microbiome & Chronobiology Research at Rush University

Ali Keshavarzian , MD, FRCP, FACP, MACG,AGAF

Our Streamlined Process

Patient Outreach and Enrollment

Our pharmacists will contact your patients to explain the CCM program, answering questions and ensuring they are engaged from the start.

Patient Outreach and Enrollment

Our pharmacists will contact your patients to explain the CCM program, answering questions and ensuring they are engaged from the start.

Device Setup and Medication Review

We manage the setup of monitoring devices and conduct comprehensive medication reconciliation, optimizing treatments based on individual patient needs.

Device Setup and Medication Review

We manage the setup of monitoring devices and conduct comprehensive medication reconciliation, optimizing treatments based on individual patient needs.

Care Coordination and Communication

We maintain direct communication with your team, addressing patient concerns, scheduling follow-ups, and ensuring seamless coordination of care.

Care Coordination and Communication

We maintain direct communication with your team, addressing patient concerns, scheduling follow-ups, and ensuring seamless coordination of care.

Personalized Care Plans

Each patient receives a tailored care plan, documented in their chart, with ongoing monitoring and goal-setting by our pharmacists.

Continuous Support and Reminders

Our team schedules follow-up calls and sends text reminders (with patient consent) to keep patients engaged and informed throughout their care journey.

Continuous Support and Reminders

Our team schedules follow-up calls and sends text reminders (with patient consent) to keep patients engaged and informed throughout their care journey.

Our Services

We believe in providing comprehensive healthcare for every stage of life. Our dedicated team of specialists offers a wide range of services designed to address your unique needs.

Optimized Gut Health Plans

Through tailored dietary guidance, nutritional advice, and circadian hygiene practices, we can support improved gut health. S16 Digital Health patients will also have exclusive access to our team's scientifically formulated Proprietary Prebiotic Blend, which was recently published in the Nature group."

Our Services

Remote Patient Monitoring (RPM)

Remote Patient Monitoring (RPM) involves tracking patient readings from devices like scales, Fitbits, blood pressure monitors, glucometers, and oxygen sensors, all delivered directly to the patient’s home. These readings are integrated into the patient’s chart, and any values outside the normal range are promptly flagged for the physician's review.

Our Services

Chronic Care Management (CCM)

Chronic Care Management (CCM/PCM) programs aim to improve health outcomes and reduce unnecessary hospital costs. These services include a personalized care plan within a certified EHR, enhanced communication between patients and care teams, prescription management, referrals, and regular reviews of patient progress.

Our Services