Care Management

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