Chronic care management
Steady, planned care for diabetes, blood pressure, asthma, thyroid and other long-term conditions, with a nurse care manager between visits.
- 20 to 30 minutes per follow-up
- Both clinics and video
Long-term conditions go better with a plan and a team that keeps track. You'll have regular visits with your own clinician and, if you join our chronic care program, check-ins with our nurse care manager in between. Home readings, refills and small questions don't have to wait for the next appointment.
Book this visit for
- Type 2 diabetes and prediabetes
- High blood pressure and high cholesterol
- Asthma and COPD
- Thyroid conditions
- Depression and anxiety, with referral when more support is needed
- Keeping track of many medicines
What happens at the visit
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A care plan you help write
Goals, medicines, the numbers we're watching and how often we'll meet. You get a copy in the portal.
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Visits on a schedule
Often every three to six months, in person or by video, depending on how things are going.
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Check-ins with Hannah
Program members hear from Hannah Brooks, our nurse care manager, by phone or portal message between visits.
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Home readings reviewed
Send blood pressure or sugar logs through the portal. Your clinician reviews them and adjusts the plan if needed.
What to bring
- Your home blood pressure or sugar log
- All your medicines, including vitamins and supplements
- Recent lab results from other offices
- The names of any specialists you see
Insurance and cost
Follow-up visits are billed as office visits. For people with Medicare who have two or more long-term conditions, Medicare covers a monthly care-management service. Your usual Part B cost-sharing may apply, and we explain it before you decide to join.
- Follow-up visit
- from $125
- A1c test in the office
- from $30
Questions people ask
Can you take over my diabetes care from my old doctor?
Yes. Book a new patient visit and sign a records release. We'll request your history and recent labs so we're not starting from scratch.
What does the care manager actually do?
Hannah checks in about how you're doing, reviews home readings, helps with refills and appointments, and flags anything your clinician should see sooner. She's a registered nurse, not a call center.
Can I send blood pressure readings from home?
Please do. Log them in the portal or upload a photo of your notebook. Your clinician reviews them and replies with any changes.
Other types of care
Ready to book chronic care management?
Pick a clinic, a day and a time that suits you. New and current patients can book online, and we confirm every request by text or phone.