Community Health Services
Chronic Disease Management

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.
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.
Our Locations
We provide trusted health services through highly qualified and dedicated professionals. Find the Affinia Healthcare location near you.