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Intensive Diabetic Care For Patients wit

We service patients with many types of chronic disease including Alzheimer's, Asthma, COPD, Diabetes, Hearth Disease, Obesity, Parkinson's Disease, and more. We believe that patients with chronic conditions have an important role in the management of their conditions. The CCM program is a partnership between your healthcare provider and your self care.


Historically, Edward H. Wagner, MD, MPH, Director Emeritus of The MacColl Institute for Healthcare Innovation, and former Director of The Robert Wood Johnson Foundation national program conducted research on the interactions between healthcare facilities, providers, and treatments of chronic illness care developed the chronic care model, or CCM. This service is essential for our health care team to work effectively for you. The monthly program (most insurance plans cover the monthly fee, although co-pays, co-insurance, and deductibles apply) helps patients with two or more chronic conditions by providing 24/7 access using an interactive patient portal, coordination of health care records, labs, and diagnostics, and connection with local services when necessary, among the many other requirements for CCM patients. All patients accept the terms of CCM at their initial intake appointment. 


Our CCM patients have expressed great appreciation for these services with 1) improved access to their health care, 2) immediate response to health care questions, 3) improved coordination of complex health records between providers and management by our team, and 4) assistance with community needs (such as membership at a gym or installation of vital service in home). 

STEP 1: You will meet with your physician who will design an individualized care plan for CCM staff to follow.

STEP 2: If at any time you wish to unenroll from CCM, you must give us one month notice. As we expect all of our patients to participate in CCM services, it is our right to refer you to another practice for your healthcare needs. 

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