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Oversite of care plan using the latest medical guidelines according to chronic conditions

Detailed patient education and health coaching to encourage clients to meet their individual healthcare goals

Care coordination among primary care physicians and specialists to ensure the best outcomes

Patient advocacy ensuring the client's needs are addressed by the medical team. 

Scheduling patient appointments and transportation. 

Virtually attending physician appointments to express concerns that need to be addressed. 

Frequent nursing check ins with patient to ensure that there are no immediate needs.

Conducting family meetings to discuss concerns and needs for the patient.

Medical record keeping and distribution to the clinical care team.

Administrative duties including review of medical billing, research of ancillary services, and detailed patient education to promote the best outcomes. 


Benefits for clients

  •  Higher patient satisfaction by having a dedicated medical professional ensure that they are getting the highest quality of care.

  • Better clinical outcomes by providing detailed individualized patient education, care coordination, and patient advocacy. 

  • Improved overall mental health with frequent nursing check ins 

  • Decreased Emergency Department usage by identifying potential medical issues that may be resolved in a timely manner

  • Decreased stress related to navigating the healthcare system with things such as coordinating appointments, transportation, investigating medical billing, and researching long term care options. 


Clients who may benefit from services

  • Clients who have, or were recently diagnosed with a chronic condition that needs close monitoring such as:




Chronic Pain

High cholesterol

Chronic Kidney Disease

Heart Failure

Alzheimers Dementia

Chronic Obstructive Pulmonary Disease (COPD)

History of Heart Attack

History of Stroke


  • Clients who have multiple physicians and specialists who need care coordination.

  • Clients who have a difficult time contacting their physician for routine needs

  • Clients who have frequent Emergency Department visits, and or hospitalizations. 

  • Clients who want to utilize resources to age in place, meaning that they would like to stay in their homes as long as possible.

*exclusive nurse practitioner service

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