Clinical Programs
Chronic Care Management
Chronic care management encompasses the oversight and education activities by health care professionals to help patients with chronic diseases and health conditions. Chronic care management helps patients systematically monitor their progress and coordinate with experts to identify and solve any problems that encounter in their treatment.
Palliative Care
The Palliative Care Program at FamilyCare Medical Group is for patients with a serious illness who need focused care to manage the relief of their symptoms and stress of a serious illness. Serious illness may include cancer, heart disease, kidney disease, Parkinson's disease, Alzheimer's and more. The primary goal of the Palliative Care Program is to improve one's quality of life. Palliative care is provided by a team of FamilyCare Medical Group healthcare professionals that includes a physician, nurse practitioner or physician assistant and registered nurses. Together, they work with your primary care provider to support your needs during any stage of a serious illness. Palliative care helps you better understand your condition and treatment options that will improve your ability to get through the medical plan. You can expect assistance with the managing of symptoms such as pain, nausea and loss of appetite, fatigue and shortness of breath. As well as advanced care planning discussions. Palliative care at FamilyCare Medical Group will be provided in your home or via a telehealth visit. You and your care team will determine the most appropriate setting and intervals for your visits.
Intensive Care Management
The Intensive Care Management Program is designed to assist FamilyCare Medical Group patients that may be in acute need for a personal health nurse. Acute needs arise when a patient receives a new medical diagnosis or when a patient is struggling with their current chronic conditions. All nurses are Registered Nurses (RNs) who will provide a weekly outreach call, a personal plan that summarizes all aspects of medical care, personalized education on how to prevent further acute situations and a direct phone line to their nurse to answer any questions they may have.
Transitional Care Management
Transitional Care Management involves the transitioning of a patient from an emergency department (ED) or inpatient (hospital, skilled-nursing facility, short-term rehab, etc.) stay from the facility back to their home. FamilyCare Medical Group utilizes Registered Nurses (RNs) and Licensed Practical Nurses (LPNs) who assist in ensuring that a recently discharged patient receives a phone-call within two business days post discharge to review the patient's discharge summary and ensure that the patient fully understands the information contained within it. The nurse will also schedule a follow-up appointment with the patient and their PCP within 2 calendar days for those identified as "high-risk" patients, 7-14 days for those with "moderate risk" and within 30 days for all others (depending upon the medical necessity of the patient). In providing this service, FamilyCare Medical Group patients have a decreased risk for readmission due to social determinants of health, medication errors or failure to recognize the signs and symptoms of a reoccurrence of their acute episode.
