Care Management

As a Patient Centered Medical Home, we offer specialized care management for patients who need additional services. Our Care Manager works with each practice team, finding ways to improve patient outcomes. Our in-house care manager is able to help with many aspects of your health, including but not limited to:

• Diabetes teaching

• Health and wellness coaching

• Assistance with transition of care from the hospital to home or other facilities

• Identifying community resources available for any home care needs

Care management resources:

• American Diabetes Association

• Alzheimer's Association of Rochester

• Eldersource

• Healthy Living Center

• Smoking Cessation Program

• Zones for self management: Download and print any of the hand outs below and post in a convenient area (refrigerator) so you have an easy reference. Each Zone provides recommendations of actions to take based on symptoms that are related to specific diagnoses.

  • Asthma management

  • COPD management

  • Diabetes self-care management

  • Heart failure self-care management

  • Pneumonia self-care management

  • Blood thinner (Warfarin/Coumadin) management

• Blood glucose logs (two different formats for you to choose):

  • BG log 1

  • BG log 2