Chronic Disease Management

We have a comprehensive clinical team, including board certified internal medicine doctors and in-house specialists to monitor and manage your chronic conditions. You will have a personal primary care physician trained to provide you with first contact, continuous, and comprehensive care. Your personal primary care physician will lead a team of professional and support personnel who collectively will take responsibility of your ongoing chronic conditions needs. Additionally, you personalized healthcare team will coordinate any service you may need across all elements of the complex health care system (hospitals, specialists, and nursing homes) and your community (public and private community-based services). Finally, your care will be facilitated by the use of an electronic health record (EHR), health information exchange systems and other means to assure you get the indicated care for your chronic conditions when and where you need and want it in a culturally and linguistically appropriate manner.

Hypertension Control

Approximately 1 in 3 Americans have been diagnosed with high blood pressure (Hypertension), but fewer than 50% of people with high blood pressure have their condition under control. This increase in blood pressure leads to greater risk of heart disease and stroke. Your personalized medical home team will work with you to take steps in lowering your blood pressure and keep it within the normal range.

Comprehensive Diabetes Care

Diabetes is a chronic disease marked by high blood glucose levels, resulting from the body’s inability to produce or use insulin. Especially, when unmanaged, diabetes can cause serious health complications, including hearth disease and stroke, hypertension, blindness, kidney disease, nervous system disease, amputations, dental disease and pregnancy complications. Your personalized medical home team will work with you to manage your diabetes through appropriate screenings and achieving controlled levels of blood sugar, cholesterol and blood pressure.


“Obesity” refers to body weight that is greater than what is considered healthy for an individual’s height. Obesity is associated with a number of serious health complications, including diabetes, high blood pressure, some cancers, liver disease, sleep disorders, premature death, among others. Your personalized medical home team will offer you focused advice or services to help you reach and maintain a healthy body weight.