Chronic Care Management

Patients that have two or more chronic conditions may require complex coordination and support with their healthcare team composed of specialists, pharmacist, social worker, community resources, and PCP. We will provide a dedicated care coordinator to help support and advocate for the patient by addressing health care needs such as, appointment referrals, timely prescription refills, health education and preventative health counseling. Our goal is to provide an additional means of medical and emotional support to reduce unnecessary hospitalizations and provide timely patient follow-up.