Every service we offer is designed to fill the gaps in traditional care delivery — ensuring patients receive continuous, compassionate, and evidence-based support.
Transitional Care Management (TCM)
When patients leave the hospital, the first 30 days are critical. Our TCM program ensures every patient receives timely follow-up, medication reconciliation, and care coordination to prevent costly readmissions and improve recovery outcomes.
48-hour post-discharge contact
Medication reconciliation
Follow-up visit coordination
Care plan development
Patient & family education
Principal Care Management (PCM)
Some patients need laser-focused management of a single high-risk chronic condition. Our PCM program delivers specialized attention and evidence-based interventions for conditions like diabetes, COPD, or heart failure.
Single-condition focus
Specialist-led care plans
Regular clinical assessments
Targeted interventions
Outcome tracking & reporting
Behavioral Health Integration (BHI)
Mental health is health. Our BHI program integrates psychiatric assessments, therapy coordination, and substance use screenings directly into the primary care setting — removing barriers and reducing stigma.
Depression & anxiety screenings
Substance use assessments
Crisis intervention planning
Therapy & psychiatry coordination
Integrated care documentation
Chronic Pain Management
Chronic pain requires a thoughtful, multimodal approach. We combine physical therapy, behavioral strategies, and non-opioid interventions to help patients reclaim their quality of life without dangerous dependency.
Multimodal pain assessments
Non-opioid treatment plans
Physical therapy coordination
Behavioral pain strategies
Progress monitoring
Annual Wellness Visits (AWV)
Prevention is the best medicine. Our AWV program delivers comprehensive health risk assessments, personalized prevention plans, and early detection strategies that keep patients healthier, longer.
Health risk assessments
Personalized prevention plans
Cognitive screenings
Immunization review
Advanced care planning
Continuous Care Management (CCM)
For patients juggling two or more chronic conditions, ongoing support isn't a luxury — it's a necessity. Our CCM program provides structured, monthly care management that keeps patients on track and out of the emergency room.
Monthly care coordination calls
Personalized care plans
Specialist coordination
Health monitoring & alerts
Insurance navigation support