Chronic Care Management

This program has been created to cater to the needs of patients diagnosed with Diabetes or Hypertension and involves a collaborative partnership between patient’s primary care physician and medical team that results in improved care for the patient. Our Nursing staff make scheduled periodic visits to patient’s home on a monthly basis to carry out a head to toe assessment and check and evaluate patient’s adherence to the care plan.

They also provide counselling and education on adherence to Medication protocol, Diet and Exercise regimen. The key purpose of the program is – Prevention of diabetic / hypertension related complication, Promoting and supporting self-management of condition, Preventing avoidable hospital admissions and reduction in morbidity and mortality related to diabetes/ hypertension

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Chronic Disease Monitoring Programs

Our Chronic Disease Monitoring program includes the following services –

  • Monthly home visit by Nurse to carry out the following –
    • Comprehensive Nursing assessment
    • Check on adherence to care plan
    • Check on adherence to diet, medication and exercise
    • Education on Medication management (Insulin storage ,injection techniques, how and when to take medications, introducing safety pen needles and pen devices)
    • Education on diet and lifestyle ( eating patterns and timings, hypo and hyper glycemic symptoms management ,blood glucose levels ) as well as diabetic monitoring
  • Initial free consultation by Dietitian
  • Initial free assessment by Physiotherapist