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DCHD Chronic Disease Management

Number of Patients Seen by Clinical Pharmacist

Current Value

148

2023

Definition

Description

This program supports patients with chronic conditions like diabetes, hypertension, and heart disease through a comprehensive, team-based approach. A clinical pharmacist works closely with patients to review medications, address gaps in therapy, and provide guidance on behavior and lifestyle changes.

By combining medication optimization with education and support for diet, exercise, and adherence, the program helps reduce key biometrics such as A1C, blood pressure, and cholesterol. Regular follow-ups ensure personalized care plans stay on track, improving outcomes and preventing disease progression.

Who We Serve

The Chronic Disease Management Program is designed for adults living with one or more chronic conditions, such as:

  • Diabetes
  • Hypertension
  • Heart disease
  • Hyperlipidemia
  • Chronic kidney disease

It especially benefits patients who:

  • Struggle with uncontrolled biometrics
  • Take multiple medications
  • Have frequent hospital or ER visits
  • Need support with lifestyle changes and medication adherence

The program is ideal for patients seeking personalized, team-based care that helps them take control of their health and prevent complications.

How We Impact

The Chronic Disease Management Program significantly improves patient outcomes by reducing A1C, blood pressure, cholesterol, and other key biometrics. With a clinical pharmacist guiding medication management and lifestyle coaching, patients gain better control over their conditions, leading to:

  • Fewer hospitalizations and ER visits
  • Improved medication adherence
  • Enhanced quality of life
  • Lower healthcare costs

This proactive, patient-centered model not only empowers individuals but also strengthens care coordination and supports value-based healthcare goals.

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