Care Options

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.