We provide an organized approach to Chronic Disease Care, because delivering better Chronic Disease Care is a team sport that requires a clear game plan. We follow the Chronic Care Model (CCM), which is an organizing framework for improving chronic illness care and an excellent tool for improving care at both the individual and population level. The model is based on the assumption that improvement in care requires a team approach that incorporates patient, provider, physician’s assistant, nurse practitioner, nurse and other advanced practice nurses and system level interventions, such as educators, coordinators and ambassadors. Our goal is to help patients with chronic diseases and health conditions learn to understand their condition and live successfully with it, motivate them to persist in necessary therapies and interventions and help them achieve an ongoing, reasonable quality of life.
Examples of chronic care management include:
Congestive Heart Failure
Click below for information about how to enroll in our Chronic Care Management Program (CCMP)