Primary Care, Diabetes and Chronic Care

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Chronic Care Management at DiamC


As of January 2015 Medicare began supporting chronic care management for some conditions. Chronic care management is critical in primary care as it contributes to better health for patients as well as reduced health care costs. Chronic care is defined as care needed for two or more chronic conditions expected to last at least twelve months which place the patient at significant risk of the condition(s) deterioration.

When patients come to DiamC for chronic care management they can expect a health care plan designed specifically for their conditions. Generally, chronic care plans are treated on a monthly basis, and with such regular health maintenance patients can ensure that they are getting the best health care possible for their conditions. Patients will receive a written copy of the suggested care plan with treatment goals, symptom management, medication management, and expected outcomes detailed.

Here are some of the health conditions which may benefit from chronic care management:

  • Alzheimer’s disease and related dementia
  • Arthritis (osteoarthritis and rheumatoid)
  • Asthma
  • Atrial fibrillation
  • Autism spectrum disorders
  • Cancer
  • Chronic Obstructive Pulmonary Disease
  • Depression
  • Diabetes
  • Heart failure
  • Hypertension
  • Ischemic heart disease
  • Osteoporosis