Chronic Care Management (CCM) is a crucial part of our program. This service is designed for patients with two or more chronic conditions expected to last at least 12 months or until the patient’s death, which put the patient at significant risk of death, acute exacerbation/decompensation, or functional decline.(home)

Our team of highly trained professionals work together to provide coordinated, non-face-to-face care outside of the regular office visit. We create personalized care plans, provide medication management, and ensure regular follow-ups. We also facilitate communication between different healthcare providers to ensure that all aspects of the patient’s health are taken into consideration.