Chronic Care Management

Our Goal

Our goal with Chronic Care Management is to educate and empower residents with chronic conditions to effectively achieve self-management of those conditions so that they stay healthy and avoid unnecessary hospital admissions. This effort includes implementation of the evidence-based Care Transition Interventions (CTI) Model to assist in the transition from the hospital to the home and reduce hospital readmissions for patients who are discharged from the hospital. CTI provides coordination of services to improve the quality of life for patients with chronic diseases.

Current Focus

Using the Stanford Self-Management Model and Motivational Interviewing, MHA’s Community Health Workers offer Chronic Care Support Networks (support groups) that give clients the opportunity to share information and gain accountability for incorporating healthier habits into their daily lives. These Networks provide a source of encouragement for those struggling with management of their chronic disease(s) and offers exposure to evidence-based learning tools that should help clients more easily manage their condition. To find dates and times of the next Support Network, refer to our event calendar.

Chronic Care Support Networks

If you or someone you know has been diagnosed with hypertension, click here to learn more about how you can become involved with our peer support network.

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