Chronic Care Management | HNJH
Monday, May 20, 2024  | Search
Chronic Care Management
Chronic Care Management

Chronic Disease Coordination

Helen Newberry Joy Hospital ‘s Care Coordination Program is a team-based health services program for patients with chronic health conditions.

We work with individual patients to provide coordinated health care services through partnerships made up of a variety of team members.

Care  Coordination is personalized to the health care needs of each patient and their specific requirements.

We work with the patient to help them better manage all the components of their healthcare, including:

  • Medication Management
  • Immunizations
  • HbA1C Control
  • Fall Risk
  • Dilated Eye Exam
  • Smoking Cessation
  • Screening for Depression, Hypertension, Colorectal Cancer, and Breast Cancer


In addition to the patient and the Care Coordinator, a healthcare team may include :

  • Family Members
  • Physicians
  • Specialists
  • Nurses
  • Pharmacists
  • Lab & X-ray
  • Care Givers
  • Community Services & Resources
  • other entities as needed

The patient and their Care Coordinator will work together to determine who will be on the patient’s Team. This will be different for each patient depending on their unique health conditions and needs.


The healthcare services required will vary depending on the individual patient.

The patient’s Care Coordinator will:

  • work with the patient to develop an individualized care plan specific to the patient’s healthcare needs and priorities
  • help ensure that the patient and/or their caregiver understands their role in the care plan
  • work to identify any barriers that may keep the patient from their healthcare goals (social, financial, environmental, etc.)
  • assemble the appropriate team to address the patients needs
  • help guide the patient through the network of providers, processes, and services necessary to their healthcare requirements
  • ensure the patients' healthcare records reflect the most current medical history and information
  • facilitate appropriate and timely communication between care team members
  • periodically follow up with the patient to ensure their needs are being met and their health or other circumstances and priorities have not changed
  • work with the patient and/or their caregivers to update the team and the care plan as necessary.