Chronic Disease Management

Chronic Disease Management

The aim of the TCHC chronic care program is to promote the early detection of chronic diseases, to monitor the health of chronic care patients, to reduce the risk of complications, and to encourage patients to make healthy lifestyle choices that help maximize their quality of life. Chronic care patients are invited to health and wellness classes, one-on-one nutrition & health education counseling, and assistance with medication management & referrals.

TCHC patients have access to a variety of specialized chronic disease management programs. These programs are based on proven care and treatment models and focus on connecting patients with coordinated resources and helping patients develop effective self-management skills.

Health PAC (Program Alameda County)
Health PAC is a new chronic disease management program for Alameda County adult residents. Patients who meet Health PAC eligibility guidelines and have diabetes and hypertension may qualify for this program. Benefits of the program include:

  • Access to specially tailored education materials, resources and classes.
  • An appointment reminder for primary care provider (PCP) and specialty visits.
  • Case managers who will follow each patient’s care and answer questions.

Diabetes Program
Once diagnosed with diabetes, the patient will be referred to see our diabetes case manager and to our diabetes education class. During the diabetes education class, patients will learn how to manage their disease, including:

  • The causes of diabetes.
  • The complications of diabetes.
  • How to check blood sugar and what the results mean.
  • The benefits of exercise.
  • How eating habits affect how the patient feels.
  • How to read labels at the grocery store.

Through our diabetes program, patients may also be eligible to receive:

  • Blood sugar test machine, testing strips, and lancets.
  • Medications, Glucose tablets and a Sharps container.

Hypertension Program
Just like our diabetes program, our program for hypertensive patients is coordinated by the same dedicated team. The program also includes a hypertension class and a personalized treatment plan. During our hypertension classes, patients will learn:

  • The causes of hypertension.
  • The complications of hypertension.
  •  The benefits of exercise.
  • How eating habits affect how the patient feels.
  • How to read labels at the grocery store.

For more information on our Chronic Care Programs, patients can call (510) 770-8040.