Chronic Care Management

transitionmgmtCare at Home’s Chronic Care Management program provides patients with comprehensive support to manage chronic conditions and minimize the chance of hospitalization. Our care programs go beyond the basic symptom intervention provided by most home health organizations and instead focus on positive disease management in close coordination with the patient’s physician. These focused post-acute solutions for patients with chronic diseases effectively decrease the probability of hospitalization.

Detailed clinical assessments are performed and ongoing education and monitoring work to help patients manage all aspects of their care successfully. Upon discharge from our care, patients have the information and skills to manage their chronic diseases in the comfort of their own homes.

Our chronic care programs are developed using the most current medical evidence. These include but are not limited to:

  • Diabetes management
  • Congestive Heart Failure (CHF)
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Complex Wound Care

Our goal is to encourage independent living at home with successful management of a patient’s chronic disease to minimize the probability of disease exacerbation or hospitalization. Patient involvement in care planning, together with close coordination with each patient’s personal Case Manager and physician ensures improved patient outcomes.


Medicare Certified State Licensed Home Health Agency
Private Insurance and Worker’s Compensation