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About 80% of older adults have at least one chronic disease, and 68% have at least two. Many adults with conditions such as arthritis, asthma, diabetes, lung disease, heart disease, stroke, osteoporosis, and others struggle to find ways to manage their condition. 

The HOUSE MD Chronic Disease Management Program can help.

Our Chronic disease management (CDM) programs is proactive, we provide organized sets of interventions focused on the needs of this defined population of patients. 

Our program is a multi-component effort that includes planned visits to teach patients about their disease, coach them on healthy behavior change including medication adherence, and skills for self-management of chronic conditions in partnership with a coordinated, multidisciplinary care team. Interventions are based on the Chronic Care Model, which identifies links to community resources, health system support, health care system redesign, self management and provider decision support. 

HOUSE MD CDM uses clinical information systems as essential elements to support high quality chronic disease care. 

Our program supports patients with illnesses such as diabetes, obesity, hypertension, heart failure, COPD and POST ACUTE CARE transition from hospital or rehab back home.

Beneficial Outcomes:

Improved quality of life

Improved health outcomes

Improved mental health

Reduced hospital utilization

Evidence of Effectiveness

There is strong evidence that chronic disease management (CDM) programs improve;

1-quality of life (Cochrane-Kruis 2013, Cochrane-Peytremann-Bridevaux 2015, Miller 2013b, Cochrane-Archer 2012, Drewes 2012) 

2-health outcomes for a variety of chronic conditions (Baptista 2016, Cochrane-Peytremann-Bridevaux 2015, CG-CVD, Cochrane-Kruis 2013, Stellefson 2013b, Cochrane-Archer 2012, Woltmann 2012, Drewes 2012, Pimouguet 2011, Si 2008, CG-Diabetes)

3-mental illness (Cochrane-Archer 2012, Woltmann 2012). 

4- CDM programs have also been shown to reduce hospital admissions for COPD (Cochrane-Kruis 2013) and hospitalizations and mortality for heart failure patients (Drewes 2012).

Our program utilizes high-tech remote monitoring devices from our partner QARDIO MD.  this includes the QARDIO ARM for remote blood pressure monitoring in the QARDIO BASE 2 which not only measures patients weights but also has a building full-body analyzer measuring bone density, fat percentage, muscle percentage, and water percentage. Devices like this allow our highly trained team provide cutting edge quality monitoring of patients with progressive and difficult to control disease processes.  

This allows HOUSE MD transitional and chronic disease managers to keep patients home and with loved ones, rather than in hospital beds.  

Call 631-636-6888 or visit our scheduling tab in the menu bar today for more information or to schedule an appointment!


The HOUSE MD Transitional care program reduces both healthcare costs and readmissions. We utilize the care transitions intervention model (Coleman model), transitional care model (Naylor model), and Better Outcomes for Older Adults through Safe Transitions (BOOST) model.

Call our corporate office at 1-800-484-3102 ext 705 to schedule a meeting today! 


For Appointments 1-833-266-7171