Chronic Disease Management in a Community Setting

1. Describe the demographics of the practice community
2. Identify a patient with one or more of the following health problems:
1. Obesity
2. Diabetes
3. Asthma
4. Hypertension
5. Substance abuse
6. COPD
7. Hyperlipidemia
3. Obtain a three (or more) generation family history (genogram).
1. Include significant medical disorders
2. Emphasis on genetically relevant issues
3. Include significant behavioral disorders such as

                                                               i.      Alcohol abuse

                                                             ii.      Violence

                                                            iii.      Psychosis

                                                           iv.      Depression

                                                             v.      Suicide

4. Create a prospective care plan for the patient’s health profile including:
1. Prevention needs:  overall and disease specific

                                                               i.      Primary

                                                             ii.      Secondary

                                                            iii.      Tertiary:  Chronic disease management

2. Medications
3. Monitoring for disease control and progression

                                                               i.      Laboratory assessments

                                                             ii.      Exam focuses

                                                            iii.      Management goals

                                                           iv.      Follow-up parameters

4. Behavioral modification needs
5. Educational needs such as:

                                                               i.      Therapeutic lifestyle changes

                                                             ii.      Disease specific knowledge

                                                            iii.      Resource availability

                                                           iv.      Self-management skills: setting and meeting goals

6. Resource needs such as (but not limited to):

                                                               i.      Transportation

                                                             ii.      Financial

                                                            iii.      Emotional support

                                                           iv.      Consultation services

                                                             v.      Skill development

5. Identify resources in the community that might assist in the patient’s treatment plan focusing on one or two patient identified self-management goal
1. Assess availability
2. Assess barriers to access
3. Assess appropriateness as applicable to the patient
6. Introduce resources to the patient
1. Document response
7. Brainstorm solutions to barriers
1. Individual
2. Community
3. System
4. Family
5. Technology, etc.

You are encouraged to consider a home visit with the patient, especially if the office visit does not allow time to obtain the necessary family history.  This is NOT required.  A “windshield” tour of the patient’s neighborhood will be useful as well.  You will use the skills that you learn in the Community Health Orientation to approach this project.

Use the chronic disease management template to report  your findings.

Be prepared to discuss the process of evaluation and discovery at debriefing.