Chronic disease management at home
A hospital admission for chronic illness is often the end of a slow slide that started weeks earlier. Regular visits at home catch that slide while it is still a phone call and a medication change.
Conditions we follow
Type 2 diabetes, hypertension, congestive heart failure, COPD and asthma, chronic kidney disease, atrial fibrillation, osteoarthritis, hypothyroidism, and the combinations of these that most older adults actually live with.
We manage the whole picture rather than one organ at a time, which matters when a medication that helps the heart is hard on the kidneys.
What ongoing care looks like
Patients with an unstable condition are typically seen every four to six weeks; stable patients every two to three months. Between visits, our nurse line takes weight logs, blood pressure readings and glucose numbers, and flags anything drifting the wrong way to your provider that day.
Every visit includes a full medication reconciliation. We physically look at every bottle, including the ones a specialist added and nobody told us about.
Fewer hospital trips
Medicare has tested this model directly. Its Independence at Home demonstration paid practices to deliver primary care in the homes of people with multiple chronic conditions, and reported reductions in hospital use among them. The mechanism is not complicated: a swollen ankle noticed on Tuesday is a diuretic adjustment, while the same ankle ignored until Saturday is an ambulance.
Where we provide this
Morris County
Boonton, Chatham, Chester, Denville, Dover and 14 more towns.
Essex County
Belleville, Bloomfield, Caldwell, Cedar Grove, Essex Fells and 13 more towns.
Union County
Berkeley Heights, Clark, Cranford, Elizabeth, Fanwood and 12 more towns.
Somerset County
Basking Ridge, Bernardsville, Bound Brook, Branchburg, Bridgewater and 12 more towns.
Passaic County
Bloomingdale, Clifton, Haledon, Hawthorne, Little Falls and 11 more towns.
Bergen County
Bergenfield, Cliffside Park, Englewood, Fair Lawn, Fort Lee and 13 more towns.
Questions about chronic disease management
Do you replace my cardiologist or nephrologist?
No. We are your primary care practice and we coordinate with your specialists, send them notes and make sure their recommendations do not collide.
Can you draw blood at home?
Yes. In-home phlebotomy is part of routine chronic care, and results come back to you by phone, usually within two business days.
Conditions we manage with this
Other care we bring to the home
Primary Care House Calls
A full primary care visit in your living room, exam and all.
Read moreMedicare Annual Wellness Visits
The yearly Medicare wellness visit, done at your kitchen table.
Read morePost-Hospital Transitional Care
A visit within days of discharge, when readmission risk is highest.
Read moreGeriatric and Dementia Care
Calm, unhurried care for older adults, including patients with dementia.
Read moreReady for a visit at home?
Call and speak with a real person. We will confirm your insurance, find a time and come to you.
973-607-4911 Call now