Chronic Disease Management

Community Health Services

Overview

Affinia Healthcare initiated the Chronic Disease Management (CDM) program in 1998 with a diabetes collaborative sponsored by the Bureau of Primary Health Care and the Institute for Health Care Improvement. Chronic diseases are debilitating, and the most commonly occurring are cardiovascular disease, asthma, cancer and diabetes.

Since Affinia Healthcare instituted the CDM program, staff have participated in other bureau-sponsored collaboratives: cancer screening and treatment; attention deficit hyperactivity disorder (ADHD); and asthma. To help combat these diseases, the CDM department provides in-home coaching and support to patients suffering from chronic diseases. Health care coaches educate patients on the importance of ownership of their medical care management. Also, in conjunction with the clients’ physicians, the coaches provide clients with self-management options to improve their quality of life. Cluster clinics and support groups have been established to provide peer support.

Patient Centered Health Home Program

The need for improved management of patients with chronic diseases in St. Louis is great.

The Patient-Centered Medical Home (PCMH) is a team approach to improving patient care and quality of life. It is a model of care that puts patients at the forefront and helps build better relationships between patients and their clinical care teams. Missouri was the first state to have Health Home State Plan Amendments approved in 2011.

Affinia Healthcare launched its Patient Centered Health Home (PCHH) Program for patients with Medicaid health insurance in April 2012. We have grown from two to six RN Nurse Case Managers (NCM), including a Pediatric Nurse Case Manager, with each managing and monitoring a monthly caseload of 250-275 patients via touches (an attempt to reach, educate, and engage the patients in their care).

For more information on the PCHH program, please call 314-898-1693.

Click the following link for more information: PCHH Brochure

For more information on Chronic Disease Management, call Affinia Healthcare at 314-814-8700.