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CHRONIC CARE MANAGEMENT · MONTHLY SUPPORT · COVERED BY INSURANCE
Ongoing Support for Your
Long-Term Health
Managing a chronic condition takes more than one appointment a year. Our Chronic Disease Management program gives patients with long-term health conditions a dedicated care team, a personalized plan, and monthly check-ins — so you're never navigating your health alone.
- What This Program Is
More Than Just a Check-Up
You'd be surprised how much can be addressed without coming in. Here's what our providers handle virtually every day.
If you're living with a condition like diabetes, heart disease, high blood pressure, or COPD, managing it well requires consistent attention — not just a visit every few months. Things change. Medications need adjusting. New symptoms arise. Questions come up between appointments and go unanswered.
Our Chronic Disease Management program is built to fill that gap. You get a dedicated care team that checks in with you monthly, helps coordinate all parts of your care, manages your medications, and is available to answer questions by phone whenever you need them.
It's the kind of attention and support that was once only available to patients with a concierge doctor — now available to our patients, and often covered at no cost through Medicare and all major insurance plans.
What's Included in Your Program
✓ A written, personalized care plan reviewed regularly
✓ Monthly check-in calls from your dedicated care coordinator
✓ Medication management and review
✓ Coordination with specialists, labs, and pharmacies
✓ A direct phone line to your care team, any time
✓ Progress tracking and goal setting
✓ Care transitions support (hospital to home)
✓ Patient education and health coaching
- Conditions We Support
We Help Patients Managing a Wide Range of Chronic Conditions
This program is designed for patients with two or more chronic conditions — but our team will discuss your situation individually to determine the best level of support for you.
Type 2 Diabetes
Blood sugar management, medication review, and lifestyle support
Hypertension
Blood pressure monitoring, medication optimization, and lifestyle coaching
Heart Disease
Ongoing cardiac support, specialist coordination, and symptom monitoring
COPD / Asthma
Respiratory management, inhaler reviews, and flare prevention
High Cholesterol
Lipid management, medication review, and cardiovascular risk reduction
Arthritis & Joint Disease
Pain management support, mobility goals, and specialist coordination
Chronic Kidney Disease
Lab monitoring, dietary guidance, and nephrology coordination
Obesity & Metabolic Syndrome
Weight management, nutritional support, and complication prevention
- The Difference It Makes
Why This Level of Support Matters
From routine check-ups to advanced wellness programs, we bring everything together so you don't have to navigate multiple providers.
Fewer Hospitalizations
Patients enrolled in chronic care management programs have significantly lower rates of emergency room visits and hospital admissions. Catching problems early — and addressing them before they escalate — keeps you healthier and out of the hospital.
Better Medication Management
Managing multiple medications is complicated. Our team reviews all your prescriptions to check for interactions, ensure proper dosing, and simplify your regimen wherever possible. If something isn't working, we adjust — you don't have to wait for your next scheduled visit.
Real, Achievable Goals
We work with you to set health goals that are realistic and meaningful to your life — not just numbers on a chart. Whether it's a lower A1C, walking without pain, or sleeping better, we track your progress and celebrate every step forward.
Your Care Team Picks Up
One of the biggest frustrations in healthcare is calling your doctor's office and never actually getting through to someone who knows your case. In this program, that changes. You have a dedicated care coordinator assigned to you — someone who knows your history, tracks your progress, and is reachable directly. No phone trees, no leaving messages with the front desk, no waiting days for a callback. When something comes up, you call and you get someone who can actually help
You Don't Have to Manage This Alone
If you're living with a chronic condition, our team wants to be in your corner. Ask about the program at your next visit or call us today — enrollment is simple and takes just a few minutes.
Often fully covered by Medicare
Ask us about eligibility today