Chronic Disease Management Program

The Chronic Disease Management Program and the Disease Registry are collaborative programs that work to improve the health of patients with ongoing health problems such as diabetes, hypertension and high cholesterol. The program is managed by a health professional who is responsible for maintaining the registry, coordinating disease caregiving efforts within the Clinic and providing case management to individual patients.

The Program is an innovative effort toward preventing and managing long-term health problems such as diabetes. At the close of 2007, over 600 adult diabetics were enrolled in the Disease Registry, with plans to expand our focus to patients with hypertension and high cholesterol.

For some patients, the program manager provides weekly phone calls help them remember to take their diabetes medication, get their blood tests drawn and take care of their eyes and feet. For other patients, the program serves as a resource they can access on those occasions when something is needed, such as a voucher for an eye exam. For still others, classes given by our behavioral psychologist and nutritionist help them understand the disease they have and how to control it with medication, diet and exercise.

The program relies upon the Chronic Disease Prograqm Manager and the active participation of many other clinic staff members and volunteers. Doctors, nurse practitioners, physician assistants, nurses, health educators, health promoters, a nutritionist and a behavioral psychologist all participate in directing the program and providing

How can I help you today?

The following is a story from the August 2007 edition of the Clinic's e-mail newsletter, the Voice. Please contact the if you have any questions about this article. [Update: Please note that Bea Smith is no longer with the Program.]

“What can I help you with today?”

Picture of Bea Smith, RN, CNSBea Smith, RN, CNS, (right) wants to know how she can help her patients, and she knows that the best way to find out is to just ask them. Bea calls this the “Empowerment Approach” - she believes it is important to take the time to learn about her patients’ lives if she is going to help them improve their health.

Bea is crucial to the Clinic’s mission of improving our patients’ health because she works with one of our most at-risk populations – adult diabetics. Diabetes is not only a major health risk itself; it is also linked to other major health problems: hypertension (high blood pressure), high cholesterol and heart disease.

Bea is the manager of the Clinic’s year-and-a-half old Chronic Disease Management Program and our new Disease Registry software. The program represents an innovative effort toward preventing and managing long-term health problems such as diabetes. Over 600 adult diabetics are now enrolled in the Disease Registry, with plans to expand our focus to patients with hypertension and high cholesterol.

For some patients, weekly phone calls help them remember to take their diabetes medication, get their blood tests drawn and take care of their eyes and feet. For other patients, the program serves as a resource they can access on those occasions when something is needed, such as a voucher for an eye exam. For still others, classes given by our behavioral psychologist and nutritionist help them understand the disease they have and how to control it with medication, diet and exercise.

This program would not be possible without the clinic’s amazing staff, ready to take on the challenge.

Bea is the nurse in charge of the program and primarily responsible for its direction. She provides case management to patients and is starting a clinic soon to address diabetic health concerns. She also provides referrals to patients for eye and foot exams, prepares charts for patient visits to Clinic health providers so that the right interventions are remembered, and serves generally as a resource for these patients. In addition to these patient responsibilities, Bea oversees the Disease Registry.

However, the Program relies on the active participation of many other Clinic staff members and volunteers. Our doctors, nurse practitioners, physician assistants, nurses, health educators, health promoters, nutritionist, and psychologist all participate in directing the program, giving input and providing patient care and outreach. Without so many working together for one goal, this tremendous effort involving so many patients would not be possible.

One of the keys to the success of the Chronic Disease Management program is its emphasis on listening to what the patients want and need. For most of its first year in existence, Clinic staff members have listened to the patients enrolled in the program and adjusted what we offer to fit the reality of the patients’ lives.

New efforts are just beginning – Tuesday morning exams, a health promoter class and more are on the way next year, such as adding patients with high blood pressure and high cholesterol to the program. For now, Bea Smith is just excited by the strides that they have made so far. Blood tests for sugar levels have improved, more people are getting their regular exams done, and patients are better at taking their medication.

In the year ahead, as we put into place the efforts that the patients have indicated are needed, we will begin to see even more positive results. The program has twin goals – to improve the health of those who have been diagnosed, and to prevent diabetes in those at risk for the illness. One step at a time, we move forward toward partnering with our patients in making their health, and in turn their whole lives, a little better.