In an effort to create better value for our providers and our patients we have established the Internal Medicine Care Management Team. This team consists of a PPC physician lead, a Regional care manager, RN Care Manager, and 2 MA Health Advocates. We provide services to aid the physician in managing and collecting data from their patients.

Health Coaching

We provide Health Coaching for our patients that are referred to the Care Management Team. Health coaching helps patients to develop important habits of self-management and lifestyle change. We also can assess and refer out for other services that might be needed for optimal health.

Diabetes Care

Diabetes Care is another key point of the care management team. When the patient is referred to our team we help to collect data and monitor the management of diabetes for a successful control for the patient. We will collect blood sugar readings, carbohydrate intake, and medication management following a physician’s medication adjustment schedule and overcoming social barriers to ensure success. Including teaching insulin dosing.

Hypertension Care

Hypertension Care has become one of our most common used services, we aid in monitoring high blood pressure with convenient walk in hours for blood pressure checks. We teach basic concepts of hypertension management from learning to use your personal blood pressure cuff to managing your medication and controlling your diet to assist in lowering your blood pressure.

Controlled Substance Management

We provide Narcan teaching for Controlled Substance Management, and provide transitional care when it is needed.

High-Risk Patients

We specialize in High-Risk Patients, which are patients with complex chronic conditions. Patients without proper social support or self-management will benefit from our services. We strive to make sure the patient feels 100% cared for and taken care of. Our patients become our daily lives as we work daily to care for and plan ahead for whatever may be needed to help them be successful in managing their health.