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Holding Hands

Chronic Care Management

Lakeside Primary Care offers comprehensive chronic care management services to Medicare patients with two or more chronic conditions who would benefit from having a dedicated Coordinator. Our coordinators work closely and diligently with the primary care provider. This collaboration ensures seamless and convenient communication is occurring on behalf of the patient.

Chronic Care Management Coordinators provide the following to chronic care management patients:

  • Offers support and coaching over the phone to assist with health-related concerns

  • Identifies and secures community resources that would benefit the patient

  • Keeps in regular contact with the patient to ensure care plans and goals are exceeded

  • Assists with medication management

  • Serves as a liaison between patients and their healthcare teams

  • Provides resources to help navigate the decision-making process


In addition to chronic care management, Lakeside Primary Care offers transitional care management, to those patients needing assistance with the lifestyle changes after a hospitalization. This team works with patients up to 30 days after a hospital discharge to help patients with the following: 

  • Education on disease processes

  • Provide community resources and referrals

  • Assistance with medications

  • Collaboration with those involved in the patient's care journey 


By providing the above assistance, Lakeside Primary Care can help to reduce the likelihood of readmission and emergency department visits. 


For more information about Lakeside Primary Care's Chronic Care Management and Transitional Care Management programs, please talk to your provider or call 256-266-1544. 

Patient Waiting

Chronic Care Management Conditions & Diseases

Lakeside Primary Care's Chronic Care Management program helps patients with multiple diseases and conditions. 

Some diagnoses the chronic care management team helps patients with include:

  • Diabetes

  • Hypertension

  • Congestive Heart Failure

  • Chronic Obstructive Pulmonary Disease

  • Chronic Kidney Disease

  • Atrial Fibrillation

Medical Consultation

Chronic Care Management Resources

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