Disease Management
Ascension Health created a business unit called Transformational Development. It is charged with identifying potential changes and innovations to address those challenges. It addresses six platforms: early life interventions; senior care; population-based care and chronic care; transformation in…
VA home-based primary care offers comprehensive longitudinal care for veterans with complex chronic diseases. Receive personalized care in the comfort of your own home.
What is it?Robert Wood Johnson University Hospital Somerset’s El Poder Sobre La Diabetes program improves the health and well-being of underserved Latinos and helps them prevent diabetes. The program uses nutrition and exercise to target key health indicators such as weight, glucose and cholesterol…
What is it?The Heart of New Ulm Project (HONU) is an award-winning, community-driven initiative to reduce heart attacks in the rural community of New Ulm. As a population-based prevention demonstration project, it applies evidence-informed health improvement practices in the community, health care…
What is it?HealthAware is an online health-risk assessment tool to identify an individual’s risk for heart disease, stroke, peripheral vascular disease or diabetes. If at risk, the participant is invited to receive free lab work and free education from a registered nurse, which includes ways to…
What is it?Nuestra Vida (Our Lives) is a collaborative effort between Memorial Medical Center and county government. The program improves self-managed care and preventive behaviors and increases community awareness within a cultural context, incorporating local language and culturally appropriate…
What is it?The Chronic Disease Self-Management Program is a free, six-week interactive program that teaches patients how to set personal goals and develop skills to overcome barriers needed to successfully manage chronic conditions such as arthritis, diabetes, heart or lung problems, high blood…
What is it?HeartWell is an innovative health improvement initiative to decrease the incidence of cardiovascular disease, one individual at a time. A team of registered nurses conducts health screenings, one-on-one risk factor modification counseling, chronic disease support groups and community…
What is it?The Better Breathers Club, launched in January 2014, offers education on topics related to lung disease and lung health. Monthly meetings promote skills that enable patients with chronic lung disease to better manage their conditions while also allowing members to give and receive…
What is it?The diabetes initiative was formed as a pilot program with the goal of improving the quality of care for the growing diabetic population in Sussex County. The program was implemented in 10 primary care practices, and educated providers regarding current evidence-based practices for…