Chronic Care Management in Richmond, VA
At Complete Health in Richmond, VA, we understand the importance of effectively managing chronic medical conditions such as diabetes, heart disease, COPD, obesity, high blood pressure, and many others.
Comprehensive chronic care management is designed to help patients with two or more chronic conditions navigate the complexities of managing long-term diseases. Using a proactive approach, our team reviews your medical records between visits to better coordinate care, manage your prescriptions, and evaluate the overall management of your medical conditions. Our primary care clinic in Richmond, VA is committed to delivering the highest standard of care for all patients.
Our care providers are here to facilitate compassionate, comprehensive, and personalized care to improve the management of your chronic conditions and your overall quality of life.
Senior primary care services are also available to address the unique needs of older patients, ensuring they receive tailored care that considers their specific health challenges.
Benefits of Chronic Care Management
Participating in a comprehensive chronic care management (CCM) program is a great way for patients and physicians to engage and manage chronic medical conditions. The benefits of a CCM include:
- Improved access to care. The chronic care management program provides 24/7 access to care such as a nurse call line.
- Proactive care. Monthly check-ins via telephone, telehealth, or electronic means help identify issues before the need for a hospital visit.
- Reduced hospitalizations and ER visits. Preventative care can help keep your conditions under control with the 24/7 nurse line, which can help reduce hospital visits.
- Improved health outcomes. Individual care plans can help each patient reach their healthcare goals.
- Improved patient satisfaction. Living a healthier life that results in lower healthcare costs and improved access to doctors are among a few reasons patients are happier when participating in a CCM program.
Chronic Care Management Care Plan
A chronic care management care plan is a personalized plan that addresses all the medical conditions of a patient, any concerns about their treatment, and the goals of their current treatment plan. These personalized care plans are often electronic and shared with the patient to provide visual feedback on their treatment progress.
The main components of a chronic care management care plan include:
- A comprehensive list of all medical conditions, prescriptions, and allergies.
- A documented prognosis and outcome for each condition.
- Measurable treatment goals and a strategy for managing symptoms.
- Resources and supportive measures to help each patient achieve their goals.
- Any interventions planned with a timeline to keep track of future treatments.
Providers play a pivotal role in the development, follow-up, and adjustment of chronic care plans. Our chronic care management team will work closely with you to create a personalized care plan. Then, regular check-ins will be scheduled with your doctor, nurse, or a care plan specialist to monitor your condition’s progression. Working together, our healthcare team can help patients maximize their results and provide ample feedback regarding your treatment.
Our Approach to Comprehensive Chronic Care Management
Complete Health in Richmond, VA, uses a holistic approach to manage each patient’s chronic condition. This results in a multifaceted approach that involves the use of medications, education, communication, self-help, and complementary treatments to improve the outcomes achieved.
This is accomplished by using a multidisciplinary team to help coordinate care and improve access to our patients. Through the use of a team consisting of doctors, physician assistants, nurse practitioners, and nurses, Complete Health ensures our clinics are there for you whenever we are needed.
The integration of a multidisciplinary approach allows our clinicians to check in frequently with our patients to monitor their progress, address any questions or issues that may arise, and adjust the treatment plan when needed. This helps to further enhance the personalized care provided which translates to improved outcomes and patient satisfaction.
Patient Engagement and Education
At Complete Health, we feel our patients play an integral part in controlling chronic diseases. Therefore we focus on improving their engagement in the healthcare process through a three-prong approach.
- Empowering Patients through Education. Providing appropriate educational resources and valuable information to help you better understand your health condition, empowering you to make informed decisions about your care.
- Tools and Resources for Self-Management. Similar to tuning up your car, having the right tools and resources can help in managing chronic conditions by improving health decisions related to diet, exercise, and a healthy lifestyle.
- Patient Support Systems. While empowering a patient’s ownership of their disease we remain only a phone call away for any questions or issues when they arise. Additionally, Complete Health works to identify community support networks to help patients cope with chronic diseases.
Technology in Chronic Care Management
Advancements in technology have improved access and helped patients better track and manage their health.
- Use of Telehealth and Remote Monitoring. Telehealth check-ins add a great degree of convenience to patients, in addition to many devices allowing at-home testing (blood sugar levels) to be transmitted to our team without leaving the comfort of your home.
- Electronic Health Records (EHR). Improve management by alerting clinicians and patients of upcoming screening tests and improving access of patients to their labs and clinic notes.
- Mobile Health Applications. Mobile phone apps can provide improved tracking of diet, exercise, vitals, and other health-related events to facilitate a healthy lifestyle.
Measuring Success in Chronic Care Management
Maintaining a high level of excellence in our chronic care management program starts by utilizing multiple assessments to continually improve the program.
- Key Performance Indicators (KPIs). Complete Health develops KPIs to measure various aspects of the program to ensure we are meeting all of our objectives.
- Patient Feedback and Satisfaction Surveys. The continuous evaluation of feedback and surveys from our patients helps to identify deficiencies and improve the program, molding it into a more patient-friendly experience.
- Continuous Improvement Strategies. Implementing strategies to assess and improve the program continually provides a proactive approach to identifying and fixing issues over time.
Contact Us
Interested in enrolling in a comprehensive chronic care management program?
- Call our Complete Health Glenside office at 804-262-4763 to schedule a consultation.
- Use your patient portal to schedule a consultation.
- Additionally, you can discuss the program with your healthcare provider at your next visit and our staff can help you schedule a consultation.