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Home Based Primary Care (House Calls)


Providing patients with primary care from the comfort of their home

Services covered by Medicare


Screen, arrange, & monitor In-Home help or other services

Offer counseling & support

Provide education to the caregiver

Act as an advocate for the older adult

Offer referrals to Geriatric specialists

Psychiatric care and medication management in collaboration with professionals

Conduct care plan assessments to identify problems & to provide solutions


Chronic Care Management (CCM) is the coordinated care for patients with chronic conditions expected to last at least 12 months or until death.  CCM is a critical step of patient care that has potential for better outcomes for patients.


Transitional Care provides coordination of care, with patients, to reduce hospital re-admissions.  The Transitional Care Management (TCM) plan lasts for 30 days, and begins on the date the patient is discharged from the hospital.


TCM services emphasizes prevention of exacerbation and complications, through the implementation of evidence-based guidelines and patient empowerment strategies.


Accessibility - care is typically available 24/7.  The patient is monitored via remote.  Data is collected and securely stored to the Providers records. 

Continuity of care management - communications are coordinated between family members, doctors, & other professional service providers.

Remote Patient Monitoring lends another level of care by keeping patient's chronic conditions in a digital, real-time format


There are new options available to those who cannot make it into a doctor's office.  TeleHealth is a new way of accommodating patients.  It provides a broader scope of remote healthcare services.  It is the use of technologies that include video conferencing, the internet, and digital communications.  

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