An integrative program that:

  1. Helps patients with chronic conditions and/or patients with potential long-term health consequences
  1. Each patient becomes part of a “care-team” with multiple providers and health professionals to help set and maintain the patient’s health care plan
  1. Helps patients set goals, and provides support to reach those goals
  1. Works with each patient to become and stay healthy!


What is it?

The Chronic Care Program is an integrative program to help patients who have chronic conditions be seen on a consistent basis at the Ithaca Free Clinic. Patients are seen by appointment. The first appointment is a longer appointment in which the patient and provider look to understand what chronic issues are going on and what goals the patient looks to set. Future appointments with the same provider are for treatment and maintenance of goals and chronic conditions. Referrals are also made to other providers depending on the patient’s needs.

Who are we serving?

The Chronic Care Program serves uninsured and underinsured people from Ithaca and the surrounding area with chronic conditions such as Diabetes, Heart disease, COPD, Anxiety, Depression, Asthma, Lyme disease, difficulties with weight loss, or any other chronic condition.

Integrated Care

Integrated care is what makes the Chronic Care Program a unique program at the Ithaca Free Clinic. Patients have access to acupuncture, chiropractic, massage, occupational therapy, counseling, herbal medicine, dieticians, and energy work. Referrals are made from different practitioners as well as suggestions from the patients themselves, which is highly encouraged. Using integrated care creates an atmosphere for patients to find treatments that work well together to help patients feel better overall and continue treatment so that they not only relieve symptoms but they prevent further illness.

Case Management

Each patient signed up in the Chronic Care Program becomes part of a “care team.” This care team consists of multiple providers and healthcare professionals that meet consistently to update, set goals and follow-up about each patient in the program.


Education is an important part of the Chronic Care Program. Helping each patient understand their chronic condition(s) and how they affect their bodies is half the battle to becoming healthy individuals. Our health care providers during each visit dedicate time towards education. The Chronic Care Program also strives to educate the community with educational resources of brochures and handouts about chronic conditions and community resources for health and well-being.

Educational Resources:

  • Community Resources pdf-thumbnail
  • Health Journal pdf-thumbnail
  • Services Available pdf-thumbnail
  • Health Information about:
    • Diabetes pdf-thumbnail
    • Hypertension pdf-thumbnail
    • Asthma pdf-thumbnail
    • COPD pdf-thumbnail
    • Depression pdf-thumbnail
    • Anxiety pdf-thumbnail
    • Weight Loss/ Obesity pdf-thumbnail
    • Lyme Disease pdf-thumbnail


“If it wasn’t for the Chronic Care Program, I don’t think I’d be here. I have had so many bad experiences with doctors that I avoided them for decades, but the Chronic Care Program helped heal that relationship and change my attitude. Without the program, I wouldn’t have trusted medical people enough to go to the emergency room. I would have just had that heart attack and died. Instead, I’m alive, and because of the program it has kept me healthy, I have been able to make a good recovery.” -Chronic Care Patient

“I feel like I get a lot of personal attention. I’m very comfortable seeing the medical care here, and I feel like I have a whole medical care team. The program is really achieving what it set out to do. And I would absolutely recommend this program for somebody.” – Chronic Care Patient