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Our Disease Management Program provides individuals with comprehensive support to manage a single health issue and improve their overall health through ongoing support of the disease. We go beyond the basic symptom intervention and focus on positive disease management by performing detailed clinical assessments, providing ongoing education, and monitoring work to help manage all aspects of each person’s care successfully using the blend of technology via our MyCharlie app and in-person assessments.

Our goal is to encourage optimal health for individuals with a single disease to minimize the probability of disease exacerbation, unnecessary physician office visits or hospitalization – along with ensuring the individual does go the physician when needed to avoid a condition worsening and requiring hospitalization. The individual is involved in care planning, together with close coordination with providers to ensure improved outcomes and lower costs.


  • Evidence-based nursing care protocols for each disease
  • Medication management and reconciliation
  • Home & social assessment which impact patient lifestyle
  • Disease care education & personal health record monitoring
  • Telehealth monitoring using state-of-the-art equipment
  • Monitoring patient compliance with follow-up appointments
  • Lifeline emergency response system education

Our disease management programs uses the most current medical evidence and utilizes the latest telehealth technology. Skilled nurses routinely provide an extensive range of services in the comfort of home for these and other conditions:

  • Diabetic Care
  • CHF Care
  • COPD Care
  • Pneumonia Care
  • Oncology Care
  • Dementia Care