Chronic Disease Management

Welcome to your Patient Centered Medical Home. We have a comprehensive clinical team, including Board Certified Internal Medicine physicians and In-House Specialists to monitor and manage your chronic conditions. Your Primary Physician will lead a team of professionals and support personnel who collectively will take responsibility of your ongoing chronic conditions. Additionally, your care team will coordinate any service you may need across all elements of the complex healthcare system:
  • Hospitals
  • Specialists
  • Public community – based services
  • 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.
chronic dicease management

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