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Chronic Conditions Management



Each program has care managers or case managers and a program assistant. The Care Managers are Registered Nurses in an Expanded Role or Pharmacists with a Doctorate Degree in Pharmacy. Your Primary Care Provider in Medicine will need to refer you to one or more of the CCM programs if you need closer management of your condition.

The staff in these programs received specialized training to specifically care for members with these conditions. They remain up to date with the latest clinical practice standards and assist to ensure the quality of care delivered in our medical center. All of them are extremely caring and dedicated to the members referred to their program.


The population outreach teams support multiple programs with a focus on prevention and cancer monitoring. Trained staff working in these programs include clinical pharmacists, nurses, and program assistants. The goal of these programs is to prevent diseases such as cancer and heart disease or monitor patients who have abnormal results/cancer so patients can lead healthier lives.


Generic services offered by our CCM Programs are listed below:

  • Education and Support for lifestyle modification including nutrition, exercise and smoking cessation counseling.
  • Medication management.
  • Individualized treatment plans tailored to your lifestyle.
  • Visits are conducted and offered in a variety of forms: group, face to face, or telephone. Staff may also contact you via email if you inform us to do so.
  • All of the programs are managed for a defined period of time.
  • After you have graduated from the program, future contacts are re-directed to your Primary Care Provider.