Chronic Care Management

Our Chronic Care Management program helps patients better manage their health and improve their quality of life with the assistance of a care manager. If you have two or more chronic conditions, you may qualify for this program. 

How our program works:
 

1. Our Initial Encounter:  Our medical providers have the pleasure of meeting our patients, in which we will focus on obtaining a very detailed history and physical exam. We will start with lab work so we develop a better understanding of our patient's overall health.
2. Comprehensive Care Plan:  After the initial visit, we will assign you a care manager that will help create a comprehensive care plan that addresses current assessments, goals, treatment, and expected outcomes. The care plan will include detailed health recommendations for our patients to follow tailored to their specific conditions. This can include diet and excercise plans for chronic diseases such as hypertension and diabetes. 
3. The Care Manager:  At this step, the Care Manager will assist you in implementing and achieving  the goals outlined in your care plan with services such as Health coaching and Nutrition counseling, Motivational Interviewing, Care coordination, and medication managament. 
4. Follow-Up and Progress:  Our Care Managers will work closely with patients; following up on a bi-weekly to monthly basis to check in and discuss progress, set backs, and assist in any way necessary.