Chronic Disease Care Management Program

Under the Chronic Disease Care Management Program, a team of case managers, social workers, nutritionists, and pharmacists helps individuals ameliorate the effects of congestive heart disease and diabetes. The program targets minorities aged 60 and older who live in Somerset County. A registered nurse makes an initial home visit for a client assessment, and a case manager then makes monthly follow-up visits. Nutritionist/dieticians also visit residences and evaluate types of food found in kitchen cupboards. Then they develop meal plans, recognizing food likes and dislikes, ethnicity, and other factors. Pharmacists help participants find their way through their medications, avoiding duplication or adverse reactions that could occur when prescriptions made by one physician might conflict with those made by another. When doctors recommend exercise plans, the team encourages clients to follow through on those plans. Clients who need additional services are referred to services both within and outside the hospital.

A key goal of this program is to help clients continue to reside at home, despite serious chronic conditions.

Ten persons with congestive heart disease, seven with diabetes, and seven with both diabetes and cardiac conditions were being served during the first quarter of 2002. Using two evaluation forms, the program charts such factors as weight change, blood pressure and glucose levels, and clients’ ability to verbalize an understanding of medications, meal planning, etc. These forms serve as an ongoing record of clients’ conditions.

The program reports a “dramatic” reduction in hospital readmission rates. “It’s working,” says staff. “It’s cost-effective; people are not as actively ill as they would have been.”