Overseeing Complex Treatment Plans   

We assist patients with:      

• Medication optimization: Ensuring the right medications are prescribed at proper dosages and that drug interactions are minimized.    
        
• Treatment adjustments: Making changes to treatments based on patients’ responses and progress over time.  
         
• Lifestyle management: Recommending diet, exercise, tobacco cessation, and other healthy habits tailored for each condition.      
  
  
• Self-monitoring practices: Encouraging regular usage of devices like blood glucose monitors, inhalers, and blood pressure cuffs.       
  
  
• Collaboration with specialists: Coordinating care with pulmonologists, endocrinologists, cardiologists, oncologists, and other experts as needed. 

Regular Monitoring and Follow-Up

• Periodic check-ins based on conditions and disease severity: from monthly for poorly controlled diabetes to every 3-6 months for stable heart disease. 
     
• Evaluation of lab work, imaging studies, and diagnostic testing as indicated.    
  
  
• Physical exams to assess for complications, side effects, and symptoms of progression.   
    
• Adjustments to treatment plans based on data from monitoring and how patients are functioning day to day.
  
  
• 24/7 access in case of urgent issues or worsening symptoms between scheduled appointments.    

Comprehensive Patient Education

• Recognize “red flag” symptoms that require prompt medical attention.     
    
• Manage side effects from medications and treatments.       
     
• Perform recommended self-care activities like glucose testing, inhaler usage, and wound care.   
         
• Make healthy diet and lifestyle changes for optimal disease control.       
  
  
• Address emotional challenges like fear, isolation, and depression common to chronic illness.       
   
• Communicate effectively with providers to facilitate the most informed care possible.         

Addressing the Whole Person

We consider:

• Physical needs: Through medical management, rehabilitation, and symptom relief.      
      
• Emotional health: By validating feelings, coping with loss, and building hope for the future. 
  
  
• Social circumstances: Helping patients maintain connections and find community.        
  
  
• Financial barriers: Assisting with navigating insurance, applications for aid, and funding resources.
  
  
• Cultural factors: Respecting and accommodating the role of values, beliefs, and traditions.        

A Team Approach to Care

• Patients: Education and counseling empower individuals to self-manage their conditions.
  
  
• Family members: Caregiver training and support minimize burnout and build self-efficacy.
  
  
• Nurses: Case managers address psychosocial needs, coordinate care with specialists, and monitor for complications.
  
  
• Physicians: Primary providers oversee all aspects of care, implement treatment plans and adjust as needed.   
  
  
• Physical and occupational therapists: Help Rebuild strength, mobility, and daily functioning impacted by illness.

An Empowering Partnership

• Build patients’ confidence in self-care activities and decision-making.  
      
• Provide hope and motivation through achievable, incremental goals.        
  
  
• Meet patients where they are – both literally and figuratively – to facilitate the most customized support.     
  
  
• Foster open communication so patients feel comfortable sharing concerns, asking questions, and voicing needs.      
  
  
• Honor patients’ priorities for quality of life and independence above all else.       
  
  

If you’re living with a chronic illness and seeking a more active, empowered role in your healthcare, we invite you to discuss how we may help. Our goal is to provide the most personalized, comprehensive chronic disease management possible so you can live well – by your definition. Please contact us to learn more.