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Patient Story

Chronic Care Management

The Chronic Care Management Program from Partners HealthCare at Home helps patients with chronic illnesses – such as diabetes, heart failure and breathing problems – to better manage their health and achieve the best quality of life possible.

Our clinicians are specially trained and certified in chronic care management, which is a patient-centered approach that helps patients in their homes learn ways to manage their illness. Through coaching and education, patients and families learn self-management skills that help them feel more confident to live a healthier lifestyle.

To learn more about Chronic Care Management from Partners HealthCare at Home or to make a referral, call (844) 744-4200.

How Chronic Care Management Can Help

The management of chronic illnesses has become a critical issue in today’s healthcare environment. At least 50% of home health patients have at least one chronic illness, and that numbers are increasing.

Our Chronic Care Management Program includes five components:

  • A patient-centered approach that engages patients and builds relationships and trust
  • A collaborative partnership with the patient’s primary care physician and medical team that results in improved care for the patient
  • A self-management approach built on the principles of health coaching, evidence-based practice and adult education, which equips patients with the knowledge and tools needed to help manage their disease
  • The use of clinical specialists as consultants
  • Use of advanced technology that includes telemonitoring and electronic exchange of information among providers 

Our comprehensive Chronic Care Management has been proven to produce better health outcomes, including:

  • Improved health and quality of life
  • Reduced hospitalizations and Emergency Department visits
  • Reduced duplication of diagnostic tests
  • Reduced medical expenses, including drug costs