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Diabetes Management Program (DMP)
The purpose of the Diabetes Management Program is to improve the prognosis of high risk and non-compliant diabetic patients identified by participating providers. Once enrolled, each patient is assigned a team of healthcare workers, comprised of his/her primary care provider (PCP), a case manager, a program coordinator, a Community Health Outreach Worker (CHOW), and an administrative staff person. Patients receive six months of intensive case management in their homes, aimed at care coordination, health education, and self-management skills.
The Community Health Outreach Worker and Case Manager work together to help the patient adhere to the treatment plan prescribed by the PCP. They also facilitate access to services not available in the physician's practice, including pharmaceuticals, specialty and social services, diabetic education, or peer support. The patient's ongoing progress is continuously reported to the PCP, allowing for treatment modification/ adjustment as needed. Results are monitored and changes in behavior are observed as the patient progresses towards their pre-established goals. At the end of this period, the patient is transitioned from intense monitoring twice per week to twice per month.
Diabetes is truly a life-altering condition that affects all aspects of a person's life. A strong network of clinical and social support will foster compliance, reduce stress, minimize associated diseases and significantly improve the patient's overall quality of care.
For more information about the DMP, call (212) 342-1618.
