Chronic care management
Steady, regular attention between visits, so small changes get caught before they become hospital trips.
Example: home BP log review
Illustrative only. Home readings shared between visits help your clinician adjust treatment sooner.
Conditions we commonly help manage
We work alongside your specialists, such as cardiologists, endocrinologists, and nephrologists, rather than replacing them.
What ongoing care looks like
A written care plan
Goals, medications, warning signs, and who to call, all in one document.
Monthly check-ins
Phone or video touchpoints between visits for eligible patients.
Home readings
We'll show you how to log blood pressure, glucose, or weight, and what to do when readings change.
Adjustments
Medication changes, labs, and referrals as your needs change.
Questions
Is chronic care management covered by Medicare?
Medicare covers chronic care management services for eligible patients with two or more chronic conditions. Standard cost-sharing may apply. We'll ask for your consent and explain costs before enrolling you.
Do I need home monitoring devices?
Not always. Many patients already have a blood pressure cuff or glucose meter. We'll recommend what's useful and check that your device reads accurately.
What if my readings are dangerous?
Your care plan lists specific numbers and symptoms that mean "call us today" and those that mean "call 911." We'll review it with you.