Chronic Care Management

Our Approach

1. Chronic Care Management (CCM): For patients managing one or more chronic conditions, our CCM program provides ongoing care coordination, regular follow-up, medication support, health education, and personalized care planning. Our goal is to help you better manage your condition and reduce avoidable complications.
2. Remote Patient Monitoring (RPM): When appropriate, we use remote monitoring technology to track important health measurements from the comfort of your home. Your care team can review your readings, identify changes that may require attention, and provide timely support to help you stay on top of your health.
3. Transitional Care Management (TCM): After a hospital or other qualifying healthcare facility stay, transitioning back home can be challenging. Our TCM services help support a safe and organized transition by following up with you, reviewing medications and discharge instructions, coordinating care, and helping address concerns after your discharge.
4. Individualized Care Plans: Every patient is unique. Our providers work with you to develop a care plan tailored to your health needs, goals, and lifestyle.
5. Regular Monitoring and Follow-Up: Ongoing check-ins help us track your progress, identify changes in your condition, and adjust your care plan when appropriate.
6. Medication Management: We help you understand your medications, how to take them, and their role in your treatment plan—helping you stay on track and reduce the risk of complications.
7. Nutritional Guidance: Nutrition can play an important role in managing many chronic conditions. We provide practical dietary guidance that supports your individual care plan.
8. Lifestyle Coaching: We support sustainable lifestyle changes, including physical activity, stress management, healthy sleep habits, and tobacco cessation when appropriate.
9. Education and Empowerment: Understanding your condition is an important part of managing it. We provide education and practical guidance so you can participate confidently in your care.
10. Coordinated, Collaborative Care: Your healthcare may involve multiple providers. When needed, we coordinate with specialists and other members of your care team to promote continuity and keep everyone aligned with your care plan.

Conditions we manage