Our comprehensive program is made for you and focuses on modifying lifestyle behaviors that relate to cardiovascular disease, such as physical activity, nutrition, stress management and more. Through a holistic approach, the program is tailored to help your heart heal and improve your health and quality of life and achieve optimal recovery.

If you have two or more chronic conditions, let the Chronic Care Management
program at CIS help you manage your health care from the comfort of your own home

High Blood Pressure
or High Cholesterol
Artery Disease
Artery Disease
  • How It Works
  • Program Benefits
  • How Do I Enroll
  • How It Works

    Chronic care management communication may be via phone calls, texting, video or email. These frequent non-face-to-face visits could help reduce the need for you to come to the clinic for an in-person visit. For example, the program can allow you to have a video session to review a new medication that was prescribed for you, rather than coming to the clinic for a visit.

    We work closely with each patient to develop a unique and personalized care plan to address your needs and manage your care based on your medical history and conditions. In addition to complete care coordination with your other healthcare providers, CCM offers the convenience of having open communication to allow us to better manage your care while keeping you at home.Patients can call the CCM team through a designated phone number at any time for things such as worsening symptoms, medication refills or assistance with getting an appointment with another health care provider. CCM is designed to be your one-stop-shop in health care.

  • Program Benefits

    Chronic Care Management offers many benefits to patients which include:

    • Convenient access to your CIS physician and CCM care team through a designated phone number
    • Increased communication to help improve overall care coordination
    • 24/7 access to our CIS care team
    • Ability to offer other forms of communication such as texting, video or emailing for quick and easy access
    • Helps to improve quality of life by offering unique services such as social services and dietary support
    • Helps to reduce hospital admissions or readmissions
    • Reduces the need for frequent travel to doctor visits or unnecessary emergency room visits
    • Frequent medication review for patient safety
    • Continuity of care through your designated nurse navigator
    • More cost-effective option to manage your health
  • How Do I Enroll

    Your doctor may recommend that you enroll in the Chronic Care Management program at your clinic visit. However, you may also request to be enrolled at any time, as long as you have seen a CIS physician within one year. The CCM team will evaluate whether you qualify for the program. If you qualify, you will be asked to give written or verbal consent. Next, an initial visit will be scheduled to discuss the program and answer any questions you may have.


    All Medicare patients with two or more chronic conditions can be enrolled.

    These conditions may include, but are not limited to:

    • Atrial Fibrillation
    • Cardiovascular Disease
    • Coronary Artery Disease
    • Heart Failure
    • High Blood Pressure
    • High Cholesterol
    • Peripheral Artery Disease

    *Ask your physician or nurse if you qualify


    Yes, all enrolled patients have the option to withdraw from the program at any time. Once you withdraw from the program, you will no longer receive communication or be managed by the CCM team.


    Yes, depending on your insurance coverage, you may have a small monthly fee to be enrolled in the program. But keep in mind that this small monthly fee can reduce your need for regular visit co-pays or emergency room visits, while adding the convenience of managing your care from home.

The Chronic Care Team at CIS

Your compassionate Chronic Care team consists of CIS physicians,
nurse practitioners, nurse navigators, licensed social workers, as
well as registered dietitians.

Our Chronic Care nurse navigators will be in close communication
with your CIS physician or nurse practitioner to ensure you are
receiving the best care possible. You can also access the CIS
Virtual Care Center for any after-hour urgent needs.

Patient Testimonials

“I had truly felt like this past Christmas holiday was going to be my last with my mother, but the CCM team has given my mother her life back! I am confident she is in good hands. I am pleased with the services, personal care and compassion that my mother has received from the entire team.”

"After the dietician spoke to us about low-sodium diets, I lost five pounds in one month and my husband lost 17 pounds in one month!”

“My husband’s blood pressure was very high. I was always worried and stressed, but they were able to bring his BP down with medication adjustment. They are my angels.”


Contact Your Chronic Care Team 24/7