Chronic Disease Management

Our Chronic Disease Management programs provide personalized support from skilled case managers and clinical team members to help you take control of hypertension, tuberculosis, COPD, heart failure, asthma, and chronic kidney disease. We also tackle poor medication adherence and prevent recurring hospitalizations through proactive monitoring and education.

Conditions We Manage

• Hypertension Management: Blood pressure tracking, lifestyle coaching, and tailored medication plans.
• Tuberculosis Support: Directly Observed Therapy (DOT), adherence monitoring, and patient education.
• COPD Care: Pulmonary rehab coordination, inhaler training, and exacerbation prevention.
• Heart Failure Support: Symptom monitoring, fluid management guidance, and dietary tips.
• Asthma Care: Trigger avoidance strategies, peak-flow monitoring, and action plan development.
• Chronic Kidney Disease (CKD) Support: Lab review, nutrition modifications, and nephrology referral coordination.

Medication Adherence & Readmission Prevention

Our case managers simplify your treatment by:

• Reviewing and consolidating prescriptions
• Setting up reminders and pill organizers
• Coordinating home delivery with local pharmacies
• Conducting regular follow-ups to catch issues early

Nutrition Education & Diabetes Support

Good nutrition is key to managing chronic conditions. We offer:

• Comprehensive Nutrition Education for hypertension, heart failure, COPD, and CKD
• Specialized Diabetes Education programs to balance blood sugar and medication