Certified Chronic Care Professionals

Senior Couple In Discussion With Health Visitor At HomeProgram Features

  • Identify patients with chronic diseases and age related conditions
  • Develop partnership model of care
  • Facilitate health behavior change
  • Promote and coach healthy life style


  • Patient Identification and health risk assessment by collecting data about patients health, disease, lifestyle, and risk of adverse health events
  • Developing strategies, interventions and tools to prevent decompensations, injury, reduce hospital readmission rate and support overall physical health and well-being
  • Physician, family, and care giver engagement
  • Intervention & evaluation


  • Targeted patient centered careHealthy-Heart
  • Wellness promotion, disease management
  • Preventing disease complications and readmission
  • Organize and obtain resources required and ensure that right providers are involved and in active communication with the team.