Dr. Mary Tilak & Associates
Enriching Lives Through Connected, Coordinated Chronic Care

Twenty-three years ago, when the term ‘value-based care’ was not yet coined, Dr. Mary Tilak was quietly charting a course toward it through Dr. Mary Tilak & Associates, a multi-disciplinary primary care organization committed to delivering preventive care and comprehensive chronic disease management.

“In my role as a primary care internal medicine physician, I’ve always seen myself as the fulcrum of my patients’ care journeys, driving productive and timely collaborations with subspecialists and making an intentional effort in sharing pertinent data to ensure they receive the most holistic care possible and have the best clinical outcomes, especially those managing chronic conditions,” says Dr. Tilak, president and chief strategy officer.

Her philosophy shapes every patient encounter at Dr. Mary Tilak & Associates. Each part of the care journey—whether lifestyle changes, medication management, behavioral support or functional movement—is thoughtfully connected to ensure patients feel supported and empowered. With Dr. Tilak and her team by their side, patients know they’re never navigating their health alone; every step is a team effort toward better health.

Efficient coordination with subspecialists ensures timely intervention in critical cases. In one instance, an ultrasound revealed a large kidney mass in a patient with multiple health conditions, including obesity, diabetes and liver disease. Dr. Tilak immediately scheduled an MRI and consulted a urologic oncologist. Both doctors quickly diagnosed a likely renal cell carcinoma, setting up a same-day consultation for the patient and arranging surgery within two weeks.

Likewise, more than 16,000 patients are walking healthier paths because of Dr. Tilak’s cohesive care approach.

A patient, who is also a retired medical professional, shared, “There aren’t many with her level of commitment, compassion and expertise. She’s truly one in a million.”

Her progressive approach can now be seen in advancing patient care through technology-enabled, data-driven, risk stratification tools that proactively assess patient risk levels, leading to better care outcomes. She’s inviting like-minded tech partners to collaborate with her team on building intelligent automation (IA) solutions that improve operational efficiency, support clinical decision-making and enrich the patient-provider experience throughout the healthcare journey.

Empowering Lives With Uninterrupted Care

Caring for patients isn’t confined to the four walls of a clinic. Dr. Tilak and her team maintain a continuous presence in their patients’ lives. Using patient monitoring devices and wearables, they track progress and provide real-time support.

Patient-generated health data, including Body weight, continuous glucose monitoring, heart rate and blood pressure, are transmitted automatically to the cloud portal, where the care team, under the supervision of the primary care provider, monitors trends and intervenes.

“It might look like a simple routine, but it’s one that brings patients actively into their own care while offering essential insights for the care team,” explains Dr. Tilak. “Instead of waiting for the next appointment, which might be weeks away, the team can see what’s happening day by day and step in whenever needed—bringing high-touch care management.”

For an elderly woman with diabetes and chronic kidney disease, this approach made a world of difference. After the patient’s hospital discharge, Dr. Mary Tilak & Associates maintained continuous oversight of her progress with daily tracking of glucose levels and blood pressure. She might have waited weeks for follow-up and necessary adjustments in a traditional care model. Constant monitoring allowed the team to adjust her medications faster, avoiding hypoglycemia, a potential contributor to mental status changes. This attentive care kept her stable and safe at home, without emergency interventions or hospitalizations.

Managing chronic conditions in real time helps patients stay healthier while reducing costly ER visits and hospitalizations, ultimately minimizing total healthcare costs and improving outcomes.

More Than Medicine: A Story Of Trust And Holistic Support

Each year, 2,000 new patients and 15,000 plus established patients walk through the doors of Dr. Mary Tilak & Associates, finding medical care and a sense of hope, empowerment and personalized support. Every patient’s story becomes part of a broader narrative of healing—where complex needs are met with compassionate, coordinated care. One particularly moving example is that of a patient battling metastatic ovarian cancer. During a routine visit with her oncologist, she voiced her trust in Dr. Tilak, saying, “My primary care doctor is my quarterback, and I want her involved in my care.”

Taking her words to heart, the oncologist reached out to Dr. Tilak, initiating a collaborative approach to her care.

Together, they created a care plan that focused on chemotherapy, as well as addressing the patient’s other health needs—managing her comorbidities, supporting her nutrition and prioritizing her mental well-being. This type of coordinated care helped her live as fully as possible.

Building a Healthier Community

Fostering a healthier community starts from within. By investing in team growth and patient education, Dr. Tilak ensures every aspect of care—from individual wellness to broader population health management—is both progressive and compassionate.

Professional development is central to this approach. Dr. Tilak’s team participates in workshops that deepen their expertise in population health management, enabling them to identify and address community health trends proactively. Each month, Dr. Tilak meets with the population health team to analyze quality metrics, setting clear goals to enhance patient outcomes. Regular HIPAA training also keeps the team up-to-date on privacy regulations, with an annual review conducted by a certified HIPAA officer to maintain the highest standards of compliance. A dedicated IT team continuously monitors patient care devices, safeguarding sensitive information to ensure both security and regulatory compliance.

Patient education holds equal importance. With a special focus on prevalent issues like obesity, Dr. Tilak’s registered dietitians and nutritionists work closely with patients, teaching them to make smarter dietary choices. Personalized guidance, such as sodium reduction for those with kidney disease or blood pressure issues and carbohydrate control for diabetes management, equips patients with practical, achievable solutions for better health.

A patient expressed gratitude for Dr. Tilak’s Inches Program, saying, “When I met Dr. Tilak, she was incredibly kind and knowledgeable about weight management. She was also empathetic and concerned about what would be the best way for me to proceed. Since joining the program, I’ve lost almost 10 percent of my weight.”

Dr. Tilak also recognizes the importance of mental health in primary care. A dedicated team of primary care providers enhanced by mental health professionals and physical therapists provide therapies designed to enhance coping strategies for pain management, adherence to treatment plans and relief from anxiety and depression. This integrated approach empowers patients to embrace a well-rounded journey to wellness.

Tracking key indicators like avoidable ER visits and the rate of repeat hospitalizations for patients with chronic diseases allows Dr. Tilak and her team to identify gaps and refine early intervention strategies. Patient feedback from quality-of-life surveys adds a personal dimension. It reveals the levels to which patients feel supported in managing chronic conditions. By analyzing these metrics, Dr. Tilak keeps fine-tuning the care plans, ensuring smoother transitions across providers and enhancing the quality of patient care.

It Is Time to Rethink Chronic Disease Care

For Dr. Tilak, the future of chronic disease care hinges on a powerful synergy between healthcare and technology—a partnership that goes beyond gadgets and systems to create a personalized experience for every patient.

She envisions a world where a platform with intelligent automation integrates data from patient monitoring devices, independent labs and hospital diagnostics into one connected system, breaking down barriers that delay diagnosis and treatment. In this unified model, everyone involved in a patient’s journey communicates effortlessly, ensuring care is timely, coordinated and proactive.

Analyzing data from each point of contact enhances care efficiency. Automated systems can also help with the early discovery of patterns and risks that might otherwise remain hidden.

“It is also essential to clarify that intelligent automation is here to support our decision-making, not drive it,” says Dr. Tilak. “Our goal is to enhance, not replace, the personal touch in every patient interaction.”

Dr. Tilak’s vision is already taking shape and transforming how chronic disease care is delivered. With each innovation, Dr. Tilak and her team are building more than a healthcare model; they are creating a place of healing, partnership and empowerment. Patients find a trusted partner in their health journey, bringing a source of strength that helps families and communities embrace longer, healthier lives.

The future of chronic care is here, evolving beyond managing symptoms, and Dr. Mary Tilak & Associates will lead the journey toward better living.