In conjunction with our Physician Organization, we have an embedded Pharmacist/Care Managers who will work one on one with our patients to provide any of the following care.
Complex/Moderate Chronic Disease Care Management to address:
- Non-compliance with current treatment plan
- Medication adherence
- Chronic disease education
- Chronic disease self-management support
- Medication Management
Additional Care Management Services Available:
Benefit Navigation:
- Medical pre-approvals/pre-authorization
- Certificate of necessity
- Insurance investigation
- Tier request
- Coordination between professional/medical services
- Referrals to specialty provider
Asthma Education
- Screening and counseling
- Recent exacerbation, frequent ER visits
- Pediatric and Adult
- Non-compliance with current treatment plan regimen
Diabetes Education
- Non-compliant with insulin regimen resulting in uncontrolled hemoglobin A1C
- Recurrent, severe/ frequent hypoglycemia (blood glucose <50)
- Hemoglobin A1C >8%
- New onset/new diagnosis support
- Insulin start/adjustments
- V-Go insulin delivery system instruction/support
- Dietary education and monitoring
- Inappropriate diet and malnutrition counseling
Nutritional Support Services Specific to
- Cancer
- Chronic kidney disease
- Diabetes
- Eating disorders
- Hyperlipidemia
- Hypertension
- Irritable bowel
- Obesity counseling and support
- Unintentional weight loss/Poor appetite
Social Support Care:
- In-home Safety assessment
- Generalized coping/counseling
- Anxiety screening and education
- Caregiver stress
- Dementia screening and support
- Depression screening and support
- Behavior change therapy
- Meditation/Mindfulness methods
- Sleep training
- Substance misuse
- End of life counseling
- Access to community resources: see other services page on this website
Pediatric Social Support:
- Assess behaviors at home and in school
- Parenting education: basic discipline, organization, structuring
- Assist parent/child to develop behavior modification plan
- Assist parent/child in navigating related school issues
- ADHD assessment, support and education (child and parent)
- Grief support
- Childhood stress/stress management
- Adjustment problems
- Substance misuse
- Anger management
- Sleep problems
- Academic or social problems at school
- Assertiveness skills