Chronic Condition Management

Chronic Condition Management is a program designed to target members with specific chronic health conditions. The goal is to improve their health and functional ability by providing condition self-management education, coordinating community resources, addressing all co-morbidities and psychosocial issues that may be affecting the member’s capacity to manage their own health.
Whether our patient has one or multiple chronic conditions, is newly diagnosed or has been identified through a formal population health management predictive modeling effort, the Chronic Condition Management Program can provide the additional tools and resources for improved health outcomes.

Core Program Elements:
  • Stabilizing chronic health conditions
  • Producing a clear, practical member plan of care that addresses their healthcare needs and lists specific goals in conjunction with the physician
  • Developing a self-management plan
  • Coordinating multiple care team members ensuring continuity of care
  • Coordinating needed community resources

Ask us if you qualify for the Chronic Condition Management program at your next appointment!