The Disease Management program uses evidence-based practice standards and current clinical practice guidelines to assist patients, who have a chronic disease process, with their self-care management goals.
The program collaborates with a patient’s health care team to develop a mutual plan of care to improve a patient’s understanding of his/her disease diagnosis and to promote/maintain optimal health and wellness.
Who are Disease Managers?
Disease Managers are highly trained registered nurses who work in a specialty referral clinic at the 355th Medical Group. They receive referrals from Primary Care providers, usually, to provide health coaching and education to help patients reach a specific wellness goal, on which, the patient and provider have agreed.
Why Would I Need Disease Management?
Disease Management has longer appointment times than normal clinic encounters, which allow patients more opportunities to have meaningful discussions related to his/her specific healthcare concerns.
Disease Managers seek these opportunities to improve patients’ understanding of how proper management of their diagnosis can improve their quality of life by preventing or minimizing long-term complications.
Disease Managers do this by providing a series of classes, one-on-one appointments, and support groups that use a combination of education and motivation to reinforce a patient’s relationship with their health care team.
What Disease Management Services are Available?
Listed below are classes and conditions that Disease Managers can assist.
- Hypertension (High Blood Pressure)
- Hyperlipidemia (High Cholesterol)
They can help patients who have a new diagnosis, frequent exacerbations, or have had a recent hospitalization.
They can also assist patients who need medication education, glucometer training, or inhaler familiarization, as well as those who have not had success with their diet or are in need of general assistance with lifestyle interventions.