Ongoing Management
Chronic Disease Management
Ongoing management of most chronic conditions, focused on medication optimization, prevention of complications, and practical, sustainable treatment plans. A few examples include:
- High blood pressure & heart disease
- Diabetes & high cholesterol
- Thyroid disorders & chronic kidney disease
- COPD and asthma
- Osteoporosis
- Depression and anxiety
- Obesity & hormonal concerns
- Menopause symptoms & GERD
- Frailty, fall risk & gait instability
- Polypharmacy & cognitive decline / dementia
Medicare Patients
Medicare-Focused Care
Services tailored to the unique needs of Medicare patients, with a focus on whole-person care, coordination, and long-term wellbeing.
- Annual Wellness Visits
- Preventive service planning
- Transitional care after hospitalization
- Chronic care management
Preventive Care & Screening
Age-appropriate screenings and preventive services to identify risk early and maintain long-term health.
- Cancer screening & coordination
- Cardiovascular risk assessment
- Osteoporosis screening
- Immunization guidance
- Fall risk evaluation & frailty assessment
- Cognitive & depression screening
Acute Medical Care
We will evaluate any new or concerning complaint for established patients. Telehealth visits are available as needed. Examples include:
- Respiratory infections
- Urinary symptoms
- Abdominal discomfort
- Musculoskeletal pain
- Skin complaints
- New neurological symptoms
Medication Management
Careful review and management of medications, with a focus on safety, efficacy, and simplicity.
- Adjustment of treatment plans
- Identification of side effects or interactions
- Simplification of complex regimens
- Deprescribing where possible
Care Coordination
Coordination across the healthcare system to reduce fragmentation and maintain continuity of care.
- Referrals to trusted specialists
- Labs & imaging coordination
- Hospital and ER follow-up
- Integration of outside records
- Advance care planning
Mental Health Care
Outpatient management of common mental health conditions as part of integrated primary care.
- Depression
- Anxiety
- Sleep-related concerns
- Grief & adjustment
Lifestyle & Risk Reduction
Guidance on modifiable risk factors with the greatest impact on long-term outcomes.
- Nutrition and diet
- Physical activity
- Weight management
- Smoking cessation
