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Chronic Disease Management

Chronic Disease Management

Chronic Care Initiative

The Chronic Care Initiative focuses on the aged, blind and disabled category of Medicaid recipients. This population of Medicaid recipients frequently has complex healthcare needs. The population represents nearly 70% of the state's annual Medicaid expenditures. Funding from this initiative has allowed Community Care Partners (CCP) and Durham Community Health Network (DCHN) to provide this population with enhanced screening and assessment for services that may allow them to live more safely and healthfully in their community.

These services include in-home occupational therapy assessment without having a hospitalization to promote safety and independence, nutrition counseling, mental health screening and referral, medication therapy management review and education, and nurse case management.

You can find information on:


Cardiovascular Disease

Congestive Heart Failure

Chronic Obstructive Pulmonary Disease (COPD)


Diabetes, Hypertension and Sickle Cell Telecoaching