Care Management

What is Care Management?

Lakeshore Internal Medicine & Pediatrics utilizes an embedded, multidisciplinary care management model designed to improve outcomes for patients with chronic disease, behavioral health conditions, social determinants of health needs, and recent healthcare transitions. The team works closely with providers, staff, patients, families, community agencies, and specialists to improve patient engagement, reduce unnecessary utilization, and support patient self-management.

The philosophy of the program is relationship-based care. The care management team strives to know patients personally, understand their barriers, and provide individualized support that extends beyond traditional clinical care.

Our Team

Lisa Brink, BSN, RN Holly Bruinsma, MA

Nancy Pifer, BSN, RN Jane DeJonge, BSW

Services

Chronic disease management and education

Community resource and patient assistant programs

ED and UC Follow up

Collaborative Care Management

Care coordination support

Palliative and Hospice care plans

Along with additional services

Weight Loss

Click Link Before You Call Our Office

Click Link GLP-1 Weight Loss Medication Resource