Chronic Care Management

Our Certified Chronic Care Management Program provides patients with comprehensive support to manage chronic conditions in the home setting and improve patient and caregiver satisfaction. We go beyond the basic symptom intervention and focus on positive disease management.

Detailed clinical assessments are performed and ongoing education and monitoring work to help patients manage all aspects of their care successfully. Upon discharge from our care, patients have the information and skills to manage their chronic diseases in the comfort of their own homes.

Our goal is to encourage independent living at home with post-acute solutions for patients with chronic disease to minimize the probability of disease exacerbation or hospitalization. Patient involvement in care planning, together with close coordination with each patient’s personal Case Manager and physician ensure improved patient outcomes.

Chronic Care Program Features:

  • Evidence-based nursing care protocols for each disease

  • Medication management and reconciliation

  • Home & social assessment which impact patient lifestyle

  • Chronic care education & personal health record monitoring

  • Telehealth monitoring using state-of-the-art equipment

  • Monitoring patient compliance with follow-up appointments

  • Lifeline emergency response system education


Our chronic care programs is developed using the most current medical evidence and utilized the latest telehealth technology.


Skilled nurses routinely provide an extensive range of services in the comfort of home:

  • Diabetic Care

  • CHF Care

  • COPD Care

  • Pneumonia Care

  • Oncology Care

  • Dementia Care

Are you Eligible?

Patients qualify for the 360 Health program through their health plan and through select areas where our team can serve.