Care Coordination/Chronic Disease Management, Health Education and Nutrition Counseling, Senior Care, Specialty Referrals

Care Coordination/Chronic Disease Management

Care coordination involves organizing your healthcare needs and sharing them with everyone that is part of your care team; it ensures that every aspect of your healthcare needs are met over time. Our care coordination team addresses potential gaps to make sure you achieve your desired health outcomes and what information should be shared between your providers. We work with you to determine the best referrals for your specialty services (e.g., cardiologist, pulmonologist, or oncologist).

Chronic disease management involves managing the symptoms of long-term diseases. Managing a chronic disease requires a total health (genetics, lifestyle and environment) approach. Through our chronic disease management program, your healthcare provider can slow down the progression and help you control your symptoms and get your life back on track.

Asthma Management Program

Take a deep, refreshing breath. We help children and adults do just that by providing the treatment and guidance you need to manage your asthma. Through our asthma management program, we conduct an initial consultation and assessment, followed by appointments every three months until your asthma is controlled. If needed, patients return monthly until the appropriate treatment is found and working properly.

We treat mild, intermittent, moderate, and severe asthma. We know managing asthma and its symptoms can be confusing. We provide the education and tools you need, so you can take charge of your asthma management. We offer in-office demonstrations for using medicated rescue inhalers and create a take-home comprehensive Asthma Action Plan. This individualized plan includes clear instructions for daily medications, directions for using an inhaler and information about triggers.

We refer patients who need additional care outside of our program to a qualified allergist or pulmonologist.

Cancer Screenings

Dealing with a positive cancer diagnosis can be an emotional journey leaving you unsure of where to start. When our providers refer you to our cancer screening program, our team guides you through the appropriate steps. We review your diagnosis and medical history. We get to know you as a person, not just a medical chart.

We refer you to hospitals, cancer treatment centers and medical practices throughout the metro area that specializes in the type of cancer screening and/or treatment you need.

We partner with the American Cancer Society, Northside Mobile Mammogram and Susan G. Komen Foundation to support funding for our under-served patients to receive care, to host screening events that educate patients about the importance of cancer screenings, and to educate you on early signs and proactive steps.

Cardiovascular Management Program

Our cardiovascular management program, which is integrated with our Adult Medicine Department, offers preventative measures, screenings and monitoring.

Through a blood pressure assessment and echocardiogram, we determine whether our program is equipped to properly monitor you or if we need to refer you to a specialist. We integrate fitness and nutrition counseling in your cardiovascular management plan.

We partner with area cardiovascular clinics, including WellStar Atlanta Medical Center, Piedmont Hospital, Emory Healthcare, and others to make sure you get the cardiovascular care you need.

Diabetes Management Program

Diabetes is a disease that ravages the communities we serve. Common complications are blindness, kidney failure, amputation, and increased risk of heart attack or stroke. Our diabetes management program aims to improve A1C levels and decrease diabetes complications. Our team teaches you how to self-monitor where you live, work and play. We educate you on appropriate medications, proper nutrition and staying physically active to help you manage your condition. We also address pre-diabetic conditions to help you avoid diabetic symptoms or diagnosis.

Hypertension Management Program

High blood pressure (hypertension) is a common condition that can lead to other health problems like stroke, heart attack, heart failure, or kidney failure. Our hypertension management program aims to improve your health status with proper nutrition, fitness and medication.

We offer a free self-monitoring program. This program teaches you to measure your blood pressure where you are. It gives our provider team a more accurate view of your blood pressure outside of your office visit. Through our self-monitoring program, you and your care team can design a treatment plan to better control your blood pressure.

Obesity Management Program

Obesity consists of an excessive amount of unhealthy body fat. It's a disease that raises the risk of other disorders and health problems, such as heart disease, diabetes and high blood pressure. Our professional team works with you to create healthy lifestyle changes, to include establishing a healthy eating plan, implementing regular physical activity, addressing underlying behavioral issues that may be contributing to your obesity, and encouraging family support.

Health Education and Nutrition Counseling

Through health education and nutrition counseling, we provide education on healthy food choices, food preparation and exercise. We educate you on early warning signs, preventative steps & corrective actions to avoid or manage chronic diseases.

Seniors Care

We believe seniors are special and deserve to be treated that way. Our senior care program provides patients ages 65 years and older with quality care.

We establish a caring and trusting connection with our seniors because we truly want to help you live your healthiest life. We help you understand your medical diagnosis, prescriptions and at home health plans. We connect you to fitness programs, nutrition counseling, behavioral health, and specialists who can address every health concern.

We assist you with Medicare Insurance enrollment information. We provide Welcome to Medicare exams and annual wellness visits. Free rides are available to and from your appointments using Uber Health.

Specialty Referrals

Specialty referrals is a bridge between your primary care provider (PCP) and the specialists you need. Our referral department works closely with your provider to ensure you get timely and convenient located appointments with the best specialists, whether it's within our practices or at one of our partnering providers offices.