Chronic Disease Management Services

The Chronic Disease Case Management program's goal is to improve the health of underserved, ethnically diverse individuals with chronic disease or individuals with risk factors associated with these diseases:

• Cardiovascular Disease
• Stroke
• Diabetes Mellitus
• Obesity

Through health education, Nurse Case Manager’s help patients make behavioral and lifestyle changes so they can better manage their diseases. Our Nurse Case Mangers develop a customized plan based on each individual patient’s needs. Case Mangers focus on the following:

• Understanding chronic diseases
• Nutrition education
• Stress management
• Recognizing depression
• Physical activity plans
• Medication management
• Stroke prevention
• Blood pressure management
• Diabetes Management
• Goal Setting

The Chronic Disease Case Management Program helps the patients accomplish the goals set by their case manager with a variety of services.

Health Assessments: Baseline and quarterly follow-up health assessments are conducted for program participants and include height, weight, blood pressure, glucose, cholesterol, HgA1c and BMI screenings.

Care Plan Development: The Nurse Case Manager works with the patient to set goals that focus on behaviors and nutritional lifestyle changes, physical activity, self monitoring and clinical services.

Individual Education Sessions: The Nurse Case Manager are provided to the patient to provide the one-on-one education needed to assist patients to understand what their chronic disease is, accept their situation, make healthy behavioral changes, encourage follow-through and help them to sustain long-term changes. Plan of care is updated as progress is made.

Monitoring of Medication: The Nurse Case Manager working through the Primary Care Providers will provide assistance in helping patients with their medication needs. The Nurse Case Manager will monitor medication intake to ensure that patients are following the guidelines that primary care providers prescribe. When appropriate the patient will be referred to the Pharmacy Assistance Program to assist them with obtaining medications at reduced or not cost through the PAP programs with the pharmaceutical companies.