Chronic Conditions Management
401 Bicentennial Way
Santa Rosa, CA 95403
Advanced Care Planning/Palliative Care:
Chronic Care Coordination:
Diabetes Care Management :
Diabetes Care Management: Español
Heart Failure Program:
HIV Case Management:
Outpatient Medical Social Work:
The Chronic Conditions Management program believes that our members are the most important part of the health care team. We use best practices (high-quality treatment recommendations) in supporting the prevention and self-management of chronic conditions. Our goal is to provide members with quality medical care through education and personalized health management. Living with a chronic condition can be difficult, and we are committed to helping our members live a happier and healthier life.
- Chronic Care Coordination
- Diabetes Care Management
- Heart Failure Program
- HIV Case Management
- Outpatient Medical Social Work
- PHASE Program / Diabetes Care Management
- Travel Program
- Life Care Planning Palliative Care
What We Do:
- Support “Best Practices” and prevention for chronic conditions
- Request annual lab tests and blood pressure checks
- Ask members to attend classes and groups
- Prescribe appropriate medications
- Facilitate member education and suggest lifestyle changes
- Promote health behavioral change
- Provide care management through the Chronic Conditions Management programs
Level I care helps members who are able to self-manage their chronic conditions. Patients benefit in this level by attending emphasizing self-management.
Level II care helps members with asthma, CAD, CHF, COPD, diabetes, or vascular disease who need short-term care management support. Level II health care includes:
- Health care delivered by care managers and physicians
- Participation in one-on-one visits, group visits, and telephone support
Members must be referred by their primary care provider. This level may require a co-pay.
The Health Education Department offers many related . Many people learn best in a group when they can ask questions and meet other people who are dealing with the same issues.