Chronic Care Management

Chronic Care Management is a doctor recommended service for patients with multiple (two or more) chronic health conditions such as high blood sugar, arthritis, heart disease or diabetes. Our chronic care management nurse, also known as a health coach, works with patients to provide more consistent care between appointments. Rural communities have some of the highest mortality rates and highest healthcare costs in the nation – especially when it comes to heart disease or stroke. Therefore, our goal is to advocate for patients by collaborating with the providers at Smith County Family Practice for their care.

Our Services Include:

  • Speak regularly about your progress on achieving your goals
  • Coordinate care with other health care professionals – specialists, doctors, pharmacists, etc.
  • Ensure prescriptions are current and medications are taken properly
  • Arrange community services such as Meals on Wheels or public transportation
  • Assist you with programs such as Medicare, Medicaid, Social Security and others
  • Provide regular updates to your primary healthcare provider
  • Answer your questions and meeting your needs

The SCMH staff review your insurance package to ensure this service is covered in your benefits package. If your doctor recommends this service, it is because it can help you stay on track and out of the hospital. We all have goals we want to achieve. Your chances of success go up with the help of a health coach. Through regular conversations, our nurse is able to identify and resolve issues before it becomes a crisis situation.

“I work with each patient individually. We set one or more personal goals together. A patient may have a goal to bring down blood sugars and I can offer strategies to help. Or, maybe they want to remain independent in their own home. I help find resources to accomplish that.” – Alaina Hughes, Chronic Care Management Nurse

Related Links:

Inpatient Nursing

Physical Therapy