Chronic Care Management Program

At FamilyCare, we understand that managing one’s health often feels overwhelming. It’s a challenge we have all experienced: we set out in search of answers, only to end up with a longer list of questions.

For those living with chronic illness, or multiple chronic illnesses, this challenge is even greater—and it is present daily. Frequently though, all that is needed is a little extra support. By identifying steps that patients can take in their day-to-day life, it is possible to transform chronic illness from a constant burden into a manageable condition, improving overall well-being. This is the goal of FamilyCare’s Chronic Care Management Program, which gives patients the tools and information to become more active participants in their own care.

The service is available to all FamilyCare adult patients with two or more chronic illnesses that last more than a year. Patients enter the program through self-referral or a referral from their primary care provider. Patients are assigned a care coordinator who works with them and their provider to develop a personal care plan. Together, the team identifies barriers that may interfere with the patient’s care, sets goals, and tracks progress.

Although the program is still somewhat new, we have witnessed many inspiring transformations. These successes occur when patients begin to understand how to better recognize what their body needs—and how to overcome the obstacles that may stand in their way of providing it.

For instance, a young FamilyCare patient was diagnosed with high blood pressure. He was working long shifts at a fast food restaurant and struggling to maintain a healthy weight. There was no time in the day to return home to fix himself a well-balanced meal, so he ended up eating breakfast, lunch, and dinner at the restaurant.

His care coordinator helped him develop an achievable, healthy meal preparation plan. Three months later, the patient had lost weight and his blood pressure was back in a normal range. Everyone’s situation differs, so a complete reversal may not be possible for all chronic care patients. But, with the proper guidance and follow-through, patients can improve their quality of life.

FamilyCare’s Chronic Care Management Program is primarily a telephonic service. Most of our care coordinators live in or near the same communities as our patients, giving them a direct understanding of the health barriers their patients may face. In certain areas, we have expanded the program to include community health workers, who assist care coordinators by conducting in-person outreach and visits to patients to identify specific challenges better.

We hope to make the in-person service available to more FamilyCare patients in the future as we continue to look for more innovative ways to provide quality, whole-person care.