We understand that living with a chronic disease, such as Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF) or Hypertension, to name a few, can be challenging. The goal of our Chronic Care Clinics (CCC) is to improve the overall quality of life for patients newly diagnosed, living with chronic diseases, or transitioning to home after a recent hospital or skilled nursing facility stay. The healthcare providers at our clinics are there to help bridge the gap between physician and hospital services. This is done by closely monitoring the health of the patient and checking in to be sure the patient has what they need to improve their health.
We believe that every patient visit should be a great experience and that a strong relationship between the patient and the care team is key to improved health. We will answer any questions and ensure that all care team members (including primary care, specialists, etc.) are updated on progress made and any plan changes.
We provide a high level of care by:
- Educating about the disease(s) and how to include these into life.
- Setting and working with patients to get involved with care goals.
- Monitoring progress and adjusting the plan to meet the patients’ needs.
- Helping patients define how they are going to self-manage their condition.
Our team will take the time to make sure patients understand their diagnosis, treatments, medications and physician recommendations. These efforts help improve patient health behaviors and reduce repeat visits.
Chronic Disease Management
Our Chronic Care Clinic providers offer support to patients who are newly diagnosed or have been living with chronic diseases, including:
- Anemia of Chronic Kidney Disease
- Chronic Kidney Disease (CKD)
- Chronic Obstructive Pulmonary Disease (COPD)
- Congestive Heart Failure (CHF)
- High Blood Pressure (Hypertension)
- Smoking Cessation
What is Chronic Disease Management?
Our ultimate goal is to help keep patients out of the hospital and maintain the highest possible quality of life while managing a chronic disease. We understand that every patient is different and have different lifestyles, so we work to create a plan that works for each individual. We use recognized industry guidelines and best practices to create a customized plan for appointments, design a care plan that works, reviewing medication being taken, and lifestyle changes. Each patient will have different instructions and a different care plan based on their needs.
What to Expect
During your first visit, a Nurse Practitioner will meet with you and your loved ones to understand your chronic disease process and how it affects your daily life.
During each visit, an assessment is completed, including reviewing your medications to ensure you’re managing your prescriptions and we will discuss any reasons that might get in the way of taking medications.
We will discuss your goals and create a plan of care that meets your needs, including a customized plan for your diet and medication. Additionally, we offer alternative choices that patients can change daily to improve their overall quality of life. Your individualized plan will grow and change as you learn more about your diagnosis and become better able to self-manage.
Lastly, we encourage patients that if they are having increased symptoms to call so we can get you in immediately to be assessed.
Clinical Care for Patients
- Anemia treatments, including:
- Cholesterol and/or kidney bone disease management.
- Dose adjustment of an anticoagulant to prevent blood clots.
- Hypertension and/or fluid/electrolyte management.
- Laboratory monitoring of blood counts/kidney function.
Education and Support for Patients and Their Families
- Individualized plan of care.
- Education about the disease process, signs and symptoms, medications and diet and exercise schedules.
- Education and assistance to help you prepare for renal replacement therapy such as dialysis or kidney transplant.
- Education on the signs for when you need to call the clinic or your doctor.
- Support for you and your family.