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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.

Our Programs

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:

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:

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.