Chronic disease management is an important aspect of your health.
At El Buen, we use a care team to coordinate your care. Your team consists of you, your provider and medical assistant. Depending on the level of care you need, other members can include: a mental health provider, referral specialist, nutritionist, nurse, care coordinator, health educator (promotor) and other professionals.
Your care team actively works with and supports you to develop the most effective care plan to meet your needs – by understanding your unique circumstances, family dynamics, values and preferences and your cultural background. Active participation in your treatment plan is at the core of our “medical home” model for delivering care. Your care team will encourage your involvement in a variety of ways, such as asking for input about medical decisions and treatments, developing self-management goals, and seeking your participation in patient satisfaction surveys and focus groups. Your care team will also give you access to resources that support your medical care.
The Chronic Disease Management Program provides patients with Diabetes Self-Management Education (DSME), pre-diabetes, and hypertension education in a one-to-one and group setting. Nurse Care Coordinators visit with patients at the time of the office visit to assess any barriers to their care, deliver diabetes and hypertension survival skills education, help facilitate internal referrals, and participate in the creation of a plan of care along with the provider.
Case management is continued by the Nurse Care Coordinator either over the telephone or in person in between office visits with the provider. Telephone follow-up on self-care behavior is completed with all patients who receive pre-diabetes education by a specially trained Medical Assistant. Regular monitoring to ensure adherence to the plan of care is done for all patients who participate in the program.
Here are two examples of how we perform on health improvements for diabetic patients.