Our goal is to provide you with the best care possible and to minimize costs and inconvenience to you. We know your time and your health is valuable.
Chronic Care Management Program
To Qualify, Patients Must:
Have multiple (two or more) chronic conditions expected to last at least 12 months.
Chronic conditions in that place the patient at significant risk of functional decline.
The Program Includes:
Comprehensive plan of care established, implemented, and continuously monitored by a Provider.
Outline of areas of focus/improvement, expected outcome, and prognosis.
Measurable treatment goals and symptom management.
Examples of Chronic Conditions Include:
• Alzheimer’s Disease
• Cardiovascular Disease
• Infectious Diseases
• Atrial Fibrillation
• HIV / AIDS
Transitional Care Management Program
• Helps reduce likelihood of re-hospitalization or other in-patient facility stays, including skilled nursing facility stays.
• On-demand appointments with our healthcare providers.
• Assist with managing care during and after discharge; often with a new diagnosis, change in medication therapy, or specialist referral.
Diabetic Management Program
What to Expect:
• Personalized, in-home education and materials
• Clinical guidance for disease management and outcomes measurement
• Physical assessment
• Medication consultation and guidance
How Can it Help:
• Lower A1C levels
• Reduction in hospitalizations
• Improved quality of life
• Prevent or reduce diabetes complications
Benefits of the Program:
• A coordinated approach to care
• Provider oversight
• Hospitalization readmission reduction
• Clinic appointment compliance