Guidelines Chronic Care - mcg.com

1 Enhance care quality and lower costs with modular guidance designed to quickly and efficiently assess and meet the unique needs of each persons with Chronic diseases care for themselves with easy-to-understand handouts, available in both English and preventable readmissions stemming from Chronic conditions by improving treatment of Chronic conditions that contribute to them, such as heart failure and Chronic obstructive pulmonary diseases and conditions have become the leading cause of death and disability in the United States and are among the most common, costly, and preventable of all health problems. This alarming trend makes it essential that evidence-based care and disease management tools are used effectively to address Chronic care needs. Our Chronic care Guidelines can help healthcare organizations evaluate needs, identify goals, develop personalized care plans, and support effective self- care for CareGuidelinesCHRONIC CAREC hronic care Guidelines help clinicians evaluate needs, identify goals, develop personalized care plans, and support effective self- care for patients with Chronic diseases or complex care issues.

2 The modular design supports quick, efficient assessments and enables the management of multiple comorbidities and behavioral health care and Disease ManagementDesigned for persons needing telephonic or in-person support, high-intensity disease Guidelines consist of various modules clinicians can use to create comprehensive assessments and care plans, including: Enrollment establishes a person s eligibility for the case management program Start of care addresses the status of a person s medical, behavioral, and psychosocial wellbeing, helping clinicians identify needs and prioritize assessments and care plans Self- management offers disease- and condition-specific modules for assessing and improving individual understanding and self- care Health Status provides assessments and care planning tools related to specific clinical interventions, supports medication management , and covers common symptoms that may fall outside of the usual issues related to a person s Chronic condition Transition Tools covers issues related to transitions of care , including risk of hospitalization, changes in medication.

3 And post-discharge follow-up with a primary care physician or specialist Psychosocial addresses mental and behavioral health issues and social needs that may affect a person s ability to self-manage a Chronic condition Functional Status evaluates a person s ability to perform activities of daily living and instrumental activities of daily living (ADL/IADL) Wellness ascertains wellness issues, such as tobacco or alcohol use, that if addressed could improve a person s overall healthLow-Intensity Disease ManagementLow-intensity Guidelines support low-touch disease management programs with patient education materials covering topics related to the given Engagement ToolsSimple, non-technical, and often illustrated educational handouts, available in English and Spanish, that clinicians can distribute to Health, part of the Hearst Health network901 Fifth Avenue, Suite 2000, Seattle, WA 98164 | 888 464 4746 | 02/18