Over time an illness may progress.  If an illness progresses beyond treatments and medications a patient declines.  The geriatric care team assess and advise the patient, caregiver, and clinician along the way with recommendations for care, advance care plans, and community resources. 


Chronic Care Management (maintenance)

Chronic Care Management is coordinated care to help clients stay on track by getting support between their routine office visits.  Clients with multiple chronic conditions can have a significant risk of death, hospital admission or functional decline. Our care manager evaluates clients for monthly care management and after-hour access to support health care goals.

Transitional Care Management (post hospital)

Transitional Care Management is timely home-based clinical assessments after a hospital discharge. This is a vulnerable period between the inpatient and community settings.  Oversight and coordination of care between specialist, diagnostic center, pharmacy, and other services are completed by the care manager.

Palliative Care Management (serious illness)

Palliative Care Management is specialized interdisciplinary care for clients living with serious illness. The focus is on symptoms and stress associated with the illness. This care includes caregiver support and advance care planning.  Our expert palliative care team is directed by the client’s health care wishes.


Long Life Care Management

HIPAA Fax: (470) 300-1100

McDonough, Georgia

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