Chronic Disease Intervention Program

The Chronic Disease Intervention Program (CDIP) is a case management program for persons with diabetes and/or hypertension considered to be at increased risk for the development of end stage renal disease (ESRD). Intervention is provided by a team of public health nurses. A Certified Diabetes Educator is on the team.

Objectives of the program

• Improved client understanding of the disease, disease process, diet, and medications; appropriate utilization of the health care system and providers; as well as improved understanding of the need for lifestyle modifications such as smoking cessation.
  

• Improved understanding of and adherence to appropriate self-management strategies (e.g., diet, physical activity, glucose monitoring, etc.) and assistance with planning and following through with appropriate lifestyle changes (e.g., smoking cessation, increasing physical activity, etc.).
  
• Clients will achieve and maintain optimum metabolic and/or blood pressure control (according to goals established by client's provider).

Services Provided

Contact is made with clients through a combination of home visits, telephone calls, and clinic visits. Interventions are focused on self-management training and linkage with appropriate community resources. The individual's learning and self-management needs are assessed and interventions planned with the client. Services cannot duplicate those available/accessible to the client in the clinic setting or substitute for skilled home care.

Program staff are also available to speak to community groups on a variety of topics related to awareness and management of diabetes and hypertension as well as other chronic illnesses.

To be eligible individuals should:

1. Have a diagnosis of diabetes and/or hypertension.
2. Be under the care of a medical provider.
3. Be exhibiting signs/symptoms of disease complications or difficulties with self-management.
4. Be in need of additional instruction or support.
5. Not require skilled nursing care.
6. Not have a diagnosis of chronic renal failure or end stage renal disease.

For referral or information, call 340-5613.