Chronic Care Management
Ongoing Support for Your Chronic Conditions—Beyond the Office Visit
What is Chronic Care Management?
Chronic Care Management is a structured approach to providing continuous, coordinated care for patients living with multiple ongoing medical conditions.
At Smith Family Medicine, this service ensures you receive regular follow-up, personalized care planning, and direct access to your healthcare team—not just during appointments, but throughout your healthcare journey.
Who Can Benefit from Chronic Care Management?
You may benefit from this service if you are managing two or more ongoing health conditions, such as:
​
-
Diabetes Mellitus
-
Hypertension
-
Chronic Obstructive Pulmonary Disease
-
Heart Failure
-
Coronary Artery Disease
-
Chronic Kidney Disease
-
Depression
-
Arthritis
If you’re balancing multiple conditions, this service helps simplify your care and improve long-term health outcomes.
What Does Chronic Care Management Include?
Personalized Care Planning
-
Individualized care plan based on your conditions and goals
-
Preventive care strategies and health tracking
-
Medication review and optimization
Ongoing Monitoring & Check-Ins
-
Regular follow-ups between visits
-
Symptom tracking and early intervention
-
Continued communication with your care team
Care Coordination
-
Coordination with specialists, labs, and imaging
-
Medication refills and treatment adjustments
-
Support navigating the healthcare system
Access to Clinical Support
-
Guidance when new concerns arise
-
Help addressing changes before they become serious
Medication Management
-
Review for side effects and interactions
-
Support for adherence and simplification
Benefits of Chronic Care Management
Improved Health Outcomes
-
Better control of chronic conditions
-
Early detection of changes or complications
-
More proactive, preventive care
Reduced Hospital and ER Visits
-
Ongoing monitoring helps prevent urgent issues
More Personalized Attention
-
Care that continues between office visits
-
Stronger relationship with your healthcare team
Less Stress Managing Your Health
-
Clear plan and consistent follow-up
-
Support navigating complex medical needs
Why Choose Smith Family Medicine?
At Smith Family Medicine, we provide a hands-on, patient-centered approach to chronic disease management.
​
-
Consistent follow-up and communication
-
Physician-led, detail-oriented care
-
Coordination across all of your conditions
-
Focus on prevention and long-term health
Our goal is to help you stay healthier, avoid complications, and feel supported every step of the way.
How to Get Started
Getting started is simple:
​
-
Schedule an appointment
-
Review your conditions and care needs
-
Begin receiving ongoing, coordinated care
Call 337-337-1212 to get started today
