Chronic Disease Management

Chronic Disease Management (CDM) is a comprehensive approach to identifying patients with chronic diseases and improving their health. Our Chronic Disease Management Program is a collaborative effort with United Physician members and their staffs in providing comprehensive care to their patients with these diseases through the use of best practice models, training and education in self management techniques and the use of community resources. The Chronic Disease Management Program will be the catalyst for achieving the goals of creating informed activated patients managing their own care under the guidance of a prepared, proactive team.  Our goal is to provide physicians with resources and information to assist them in treating their chronic disease patients.
The Chronic Disease Management team focuses on the following conditions:
Asthma occurs when the bronchial tubes become inflamed and constricted. The muscles of the bronchial walls tighten and airways produce extra mucus that leads to difficulty breathing, repeated episodes of wheezing, breathlessness, chest tightness, and coughing.  While asthma cannot be cured, it can be controlled by being aware of warning signs and triggers and with medication.  
Please review the diagnosis and management guidelines from the Michigan Quality Improvement Consortium (MQIC) below.
For more information log onto AT&T Healthcare Community Online or contact your Chronic Disease Consultant.
Chronic kidney disease is when a patient suffers from the loss of kidney function over time that decreases the kidney’s ability to remove waste and excess water from the blood.  Complications include high blood pressure, anemia, weak bones, poor nutritional health, nerve damages, and increased risk of heart and blood vessel disease.  There are 5 stages of chronic kidney disease based Glomerular Filtration Rate or GFR, a measure illustrating how well the kidneys are cleaning the blood.
StageDescriptionGFR Level
1 Kidney damage with normal or high GFR 90 mL/min or more
2 Kidney damage and mild decrease in GFR 60 to 89 mL/min
3 Moderate decrease in GFR 30 to 59 mL/min
4 Severe decrease in GFR 15 to 29 mL/min
5 Kidney failure Less than 15 mL/min or on dialysis
Early detection and treatment can prevent chronic kidney disease from getting worse.  Please review the diagnosis and management guidelines from the Michigan Quality Improvement Consortium (MQIC) below.
Chronic obstructive pulmonary disease refers to a group of diseases that cause airflow to be obstructed and leads to breathing difficulty and related problems.  The leading cause of COPD is smoking.  Potential complications of COPD include respiratory infections, heart problems, high blood pressures, and lung cancer.  The main conditions that make up COPD are chronic bronchitis and emphysema.
Chronic Bronchitis
Chronic airway inflammation most frequently caused by smoking.  Other potential causes include air pollution, exposure to dust and chemicals, and rare genetic diseases
Emphysema
A condition in which the air sacs at the end of the bronchioles are gradually destroyed, limiting airflow out of the body
Please review the diagnosis and management guidelines from the Michigan Quality Improvement Consortium (MQIC) below.
Congestive Heart Failure (CHF) is a condition in which the body can no longer pump enough blood to meet its needs.  Complications of Congestive Heart Failure are arrhythmias, pulmonary edema, kidney damage, liver damage, heart valve problems, strokes and heart attacks.  CHF is classified as either systolic or diastolic heart failure. 
Systolic heart failure
The pumping action of the heart is reduced or weakened. 
Diastolic heart failure 
The heart can contract normally but is stiff when it is relaxing and filling with blood. This impedes blood filling into the heart and produces backup into the lungs and CHF symptoms.
Please review the diagnosis and management guidelines from the Michigan Quality Improvement Consortium (MQIC) below.
Coronary Artery Disease (CAD) is a condition in oxygen-rich blood is prevented from reaching the heart by plaque. built up inside the coronary arteries. Plaque, made up of fat, cholesterol, calcium, and other substances found in the blood, builds up inside the coronary arteries causing the arteries to narrow and reduces blood flow.  Complications of CAD include arrhythmias, chest pain, heart attacks, and heart failure.
Please review the diagnosis and management guidelines from the Michigan Quality Improvement Consortium (MQIC) below.
Diabetes is a chronic condition marked by high levels of sugar in the blood.  There are three major types of diabetes:
Type 1 diabetes 
Usually diagnosed in childhood, Type 1 diabetes patients need daily insulin injections because the body makes little or no insulin.
Type 2 diabetes
For more common than Type 1 diabetes, Type 2 diabetes occurs when the pancreas does not make enough insulin or the body becomes resistant to the effect of insulin.  
Gestational diabetes 
A type of diabetes that occurs during pregnancy, Gestational diabetes is when your body is unable to produce the insulin it needs.
Short-term complications of type 1 and type 2 diabetes include hypoglycemia, hyperglycemia, and diabetic ketoacidosis.  Potential long-term complications include cardiovascular disease, eye damage, foot damage, neuropathy, nephropathy, skin conditions, and bone and joint problems.
Potential complications for a mother with gestational diabetes include preeclampsia and subsequent gestational diabetes.  Potential complications for a baby due to gestational diabetes include hypoglycemia, jaundice, respiratory distress syndrome, increased likelihood of type 2 diabetes in the future and death.
Please review the diagnosis and management guidelines from the Michigan Quality Improvement Consortium (MQIC) below.
For more information on chronic disease management program or for ways to improve your performance, please contact your Chronic Disease Consultant.
 
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