Chronic Disease Management

Working with patients and their physicians, the SSM Health at Home team helps develop individualized plans of care for patients living with one or more chronic conditions including:

  • Congestive heart failure (CHF)
  • Chronic obstructive pulmonary disorder (COPD)
  • Diabetes
  • Acute myocardial infarction (heart attack)
  • Pneumonia
  • Depression

All SSM Health at Home nurses, therapists, and social workers are certified in chronic disease management by the National Association of Home Care. Training includes education on adult learning, health literacy, and behavioral techniques.

Staff assists patients in goal setting and the self-management of chronic conditions, enabling them to remain at home and out of the hospital. Not only does this improve quality of life, it can potentially reduce health care costs.

In addition to our chronic disease management programs, SSM Health at Home also offers telehealth monitoring, which is designed to help patients manage symptoms and reduce hospital admissions through daily monitoring.