Chronic Disease
Information and resources for healthcare partners, community organizations, and NH residents regarding Chronic Disease Programs.
The Chronic Disease Section works to improve the health and wellbeing of people in NH by increasing access to prevention interventions, quality healthcare and community resources through comprehensive health strategies.
Diabetes
- National Diabetes Prevention Program (NDPP)
- Diabetes- Self Management Education and Support (DSMES)
- Community self-management supports and HRSN
- Screening and detection of Diabetic Retinopathy and Chronic Kidney Disease
- Sustainable payment models to support team-based care
Heart Disease
- Blood pressure and cholesterol management
- Health Information Technology to improve care
- Team Based Care - e.g., community health workers and pharmacists
- Self-Measured Blood Pressure Monitoring with clinical support
- Lifestyle Change Programs such as YMCA Blood Pressure Self-Monitoring Program, Nutrition Education, and physical activity programs
Arthritis
- Physical Activity Assessment and counseling by healthcare providers
- Arthritis Appropriate Evidence Based Interventions (AAEBIs): Enhance Fitness, Ta Ji Quan: Moving for Better Balance, Walk with Ease, Arthritis Foundation Aquatic Program, Chronic Disease Self-Management Program
WISEWOMAN "NH Healthy Lives-Heart Program"
- Serves BCCP-eligible low-income, uninsured women, 35 to 64 years of age
- Reduces cardiovascular risk through screening (labs, blood pressure checks, health risk assessment)
- Referrals to healthy behavior support services (physical activity, nutrition, health coaching)
- Screening for HRSN and referral to social services
Additional overarching strategies include:
- Disease Prevention: Developing and implementing programs that promote healthy lifestyles and reduce risk factors associated with heart disease, diabetes, and arthritis.
- Health Education and Awareness: Providing resources to the public to educate them on healthy behaviors, early detection of illnesses, and preventive measures. This includes outreach programs that teach people how to manage existing health conditions or avoid the onset of diseases.
- Screening and Early Detection: Offering free or low-cost screening programs for conditions such as diabetes, and hypertension, which allow for early intervention and improved outcomes.
- Disease Management Programs: Supporting partnerships with healthcare providers to ensure consistent care.
- Data Collection and Monitoring: Tracking public health trends and monitoring the spread of diseases, using data to inform policy decisions and to direct resources where they are needed most.
- Collaboration with Healthcare Providers and Community Organizations: Working closely with local healthcare systems, hospitals, clinics, and other community-based organizations to ensure resources are used efficiently and that health services are accessible to all members of the community.
- Policy and System Development: Advocating for public health policies that promote disease prevention and health management at the local, state, or national levels.
By offering these services, this chronic disease section plays a vital role in reducing healthcare costs, improving the overall health of the population, and reducing the burden of disease on the healthcare system.
Provider Agreement Documents and Templates
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