Chronic Conditions Management

401 Bicentennial Way
Santa Rosa, CA 95403

Telephone
Advanced Care Planning/Palliative Care:
707-393-3498

Chronic Care Coordination:
707-393-4860

Diabetes Care Management :
707-393-3457

Diabetes Care Management: Español
707-393-3345

Heart Failure Program:
707-393-3174

HIV Case Management:
707-393-4837

Outpatient Medical Social Work:
707-393-3151

Travel:
707-393-4044

The Chronic Conditions Management program believes that our members are the most important part of the health care team. We use best practices (high-quality treatment recommendations) in supporting the prevention and self-management of chronic conditions. Our goal is to provide members with quality medical care through education and personalized health management. Living with a chronic condition can be difficult, and we are committed to helping our members live a happier and healthier life.

Our Programs

• Chronic Care Coordination
• Diabetes Care Management
• Heart Failure Program
• HIV Case Management
• Outpatient Medical Social Work
• PHASE Program / Diabetes Care Management
• Travel Program
• Life Care Planning Palliative Care

What We Do:

• Support “Best Practices” and prevention for chronic conditions
• Request annual lab tests and blood pressure checks
• Ask members to attend classes and groups
• Prescribe appropriate medications
• Facilitate member education and suggest lifestyle changes
• Promote health behavioral change
• Provide care management through the Chronic Conditions Management programs

Level I:

Level I care helps members who are able to self-manage their chronic conditions. Patients benefit in this level by attending emphasizing self-management.

Level II:

Level II care helps members with asthma, CAD, CHF, COPD, diabetes, or vascular disease who need short-term care management support. Level II health care includes:

• Health care delivered by care managers and physicians
• Participation in one-on-one visits, group visits, and telephone support

Members must be referred by their primary care provider. This level may require a co-pay.

Classes

The Health Education Department offers many related . Many people learn best in a group when they can ask questions and meet other people who are dealing with the same issues.