Chronic Disease 

At its most basic, a chronic disease is a persistent and continual condition that lasts 1+ years, requires ongoing medical attention, limits daily activities, and cannot be prevented by vaccines or cured by medication. The most common chronic diseases in the U.S. (in alphabetical order):

  • ALS (Lou Gehrig’s Disease)
  • Alzheimer’s Disease
  • Asthma
  • Cancer
  • Cardiovascular & Cardiac Disease 
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Congestive Heart Failure (CHF)
  • Cystic Fibrosis
  • Diabetes
  • Epilepsy
  • Stroke

+ Management 

Disease management breaks down the chronic care process into elements and offers a new perspective, one in which the patient is no longer a recipient of care but an actively-engaged member of the care team.

When a patient is in the position of actively managing their disease, the fear, anxiety, and gaps and barriers to care can be significantly lessened, reducing the risk of health decline, loss of independence and unnecessary complications or hospitalizations. 

Cardiac Care

Cardiac Care
Patients with chronic cardiac conditions — particularly CHF — are often at risk for hospitalization. Our cardiac team uses disease management with a multifaceted approach to stabilize the patient’s condition, reduce re-hospitalizations, increase independence and improve overall quality of life. LEARN MORE

Pulmonary Care

Pulmonary Care
Living with a chronic pulmonary condition affects nearly every aspect of life making it impossible to enjoy that life by significantly impairing the ability to breathe. Some pulmonary diseases are curable, while others are not. Disease management recognizes that all pulmonary diseases are treatable allowing the patient to manage symptoms, preserve independence  and improves their well-being. LEARN MORE

Diabetes Care

Diabetes Care
Diabetes is a chronic indicator that the pancreas is not producing enough insulin resulting in high blood sugar.  Without effective self-management, it can easily spiral into debilitating and even life-threatening conditions. LEARN MORE


Ensuring safe medication use.
Rx management minimizes the risk of fragmented care, adverse drug reactions, and medication errors for patients requiring multiple medications.

Improving quality of life.
We help our patients manage their chronic conditions because enjoying life is so much more than enduring.

Independence is a key component to positive health management.
Patients with an active role in managing their health are more likely to stick to treatment plans and often experience improved quality of life.

Patient engagement is a benefit.
Taking an active role in managing their health equals a patient more likely to stick to treatment plans and often experience an improved quality of life.

Free in-home assessment.
Our RN assesses each patient to determine what services are need, and to identify any potential risks in the home.

Disease management helps patients take a more active role in understanding and managing their disease to lessen the need for urgent care and unnecessary hospitalizations.

What We Do
We supports a solid care plan for our patients that best manages their chronic conditions, achieves more independence and engages patient, physician, specialized professionals and family and/or caregivers for an improved quality of life.

We Keep Things Simple
We translate necessary information into a language the patient can understand and educate the patient on best practices for self-care management.  In collaboration with physicians, we bring clarity to patients who might be confused by medical directives and disease information. Our skilled care team helps patients successfully manage medication, symptoms, mobility and other aspects of care.

We provide guidance on managing medications and stress the importance of lifestyle factors such as weight, exercise, and nutrition to ensure a positive outcome in self-care management.

We Communicate & Clarify
Our goal is to improve the patient’s quality of life and decrease the overall stress level that this condition creates helping patient to control their condition and minimize its impact. We teach our patients about their disease. We help our patients obtain the tools they need to self-manage and to identify red flags for early intervention before their condition or symptoms worsen – promoting greater independence.

We provide detailed assessment and education to help patients successfully manage medication, symptoms, mobility and other aspects of care including physical therapy, special equipment and nutritional education if needed.

We Elevate Support 
We address potential gaps and barriers in care (and their root causes) in order to engage the patient, enhance care and decrease frequent and unnecessary complications or hospitalizations in the long term.  We improve compliance to disease management and treatment plans by addressing the reasons patients may become non-compliant because non-compliant patients aren’t simply ignoring their disease management plans; they usually have a series of barriers keeping them from adherence.

We promote independence as a crucial aspect in helping our patients manage their conditions and avoid setbacks often caused by gaps and barriers to care.

Medication Management
Medication mishaps are all too common. With nearly 1/3 of U.S. adults taking 5+ medications, adverse drug events (ADE) account for nearly 700,000 ED visits, 100,000 hospitalizations per year, and represent the most common in-patient error, affecting nearly 5% of patients.  Fatigue, weakness, depression, confusion, pain, and misjudgment often contribute to medication errors that may require hospitalization. 

Medication management assists in getting the right prescriptions to the right individuals, and ensuring medication is taken at the right time. With the guidance of the patient’s MD, our team can develop a customized medication plan to ensure any medication errors are prevented.

Addressing Gaps & Barriers
We help to clarify everything a patient needs to minimize negative outcomes because gaps and barriers can make it difficult for patients to self-manage and often results in lack of patient engagement, particularly those patients with multiple chronic illnesses and complex medical needs.

These gaps or barriers can range from interpersonal issues such as between a patient and an MD to physical disabilities, emotional, social, and mental issues) all of which can lead to a negative outcome. Language, education, and cultural and ethnic barriers may also compound the problem.

Home health care provides necessary clinical care to an individual in their home. It refers to clinical services and support provided intermittently for those challenged by illness, age, disability; or those who are recovering from surgery, or an injury.

For Medicare recipients, a physician must certify that an individual needs home health care, medically necessary services to treat, rehabilitate, sustain or restore home-bound adults and seniors to their optimal health and in the setting where they feel most comfortable.

This includes skilled nursing, disease management, physical, occupational and speech therapy. 


Original Medicare Part A typically covers home care services at 100 percent, provided the services are ordered by your surgeon, are performed by skilled professionals and are medically necessary. In addition, the patient must be essentially “homebound,” meaning that it is difficult for the patient to perform activities outside the home, except to go to doctor’s appointments.

Medicare enrollees may be eligible for skilled nursing care, disease management and in-home therapy as prescribed by a physician.  

Private Insurance

Most insurance plans provide some coverage for home care services. But plans, deductibles and out-of-pocket expenses will vary. These plans generally follow the same rules as Medicare regarding payment for long-term care services. If they do cover long-term care services, it is typically only for skilled, short-term, medically necessary care.

Like Medicare, the skilled nursing stay must follow a recent hospitalization for the same or related condition and is limited to 100 days. Coverage of home care is also limited to medically necessary skilled care. Most forms of private insurance do not cover custodial or personal care services at all. Your plan may help you pay for some of the copayments or deductibles. It is best to contact your home care provider of choice prior to your surgery to see if it is in-network with your insurance company. You will also want to contact your insurance company to determine if any pre-authorization is required for home care services.

Short Term and Long-Term Disability Insurance

Disability insurance may pay all or a portion of home health and home care services. It is best to contact your policy provider to determine your coverage.

Private Pay


Gaps & Barriers to Care

Patients with multiple chronic illnesses and complex medical needs are highly susceptible to a host of negative outcomes, including medication errors; miscommunication caused by uncoordinated actions; continuation or recurrence of symptoms.

Psycho-Social Factors Creating Gaps & Barriers To Care
Patient overwhelmed by fear and confusion following hospitalization or after receiving treatment plan(s) from 1+ MDs can lead to frustration, limited absorption and retention of information communicated.

Patient may need more interaction with MD but may be too embarrassed to ask. Poor or incomplete communication creates significant barriers to a positive care experience.

2 in 5 patients with multiple chronic conditions tell their MD about their medical conditions, but not other issues that could affect their health, such as financial and/or transportation issues.

Other factors included lack of patient engagement, mental health issues, inadequate education of older adults and their family/caregivers, limited access to essential services, and the absence of a single-point person to ensure continuity of care in the home.

Cognitive impairment or deficits, cultural barriers as well as health literacy barriers can also make it difficult for patients to accomplish their goals.

Limited access to essential services or technology advancements in MD to patient communication.