Internal medicine for chronic disease management (CDM)

internal medicine katy


Chronic diseases are a huge problem in the US, and these diseases require ongoing monitoring and too much care. The compassionate, the community-based team at Premier NW Houston Medical Group near Houston in Cypress, Texas,
offers chronic disease management services to help to get the targeted care of the need for a wide range of conditions.

An estimated 99 million Americans live with a chronic illness. Meeting the needs of this population is one of the major challenges facing the U.S. health care system today and in the future.

Chronic diseases

Chronic diseases could include any condition that lasts for several months, but quite often, chronic diseases last for years. Some of the chronic diseases are:
High blood pressure (hypertension)
Chronic pain conditions
Alzheimer’s disease
Heart disease
Inflammatory bowel disease (IBD)
COPD (chronic obstructive pulmonary disease)
Long-term or incurable infectious diseases such as

The top 7 most common chronic diseases in
the U.S

-Heart disease
-Chronic lung disease
-Kidney disease

Chronic Disease Management (CDM)

Chronic Disease Management is designed to improve the coordination of patient’s health care needs. At Concierge Internal Medicine, they want to continue to get to know their patients better. An open line of communication with 24/7 medical
access is our commitment.
With careful chronic disease management, even when a patient has more than one of these conditions, could live for a long time.

Factors of CDM

Factors that can influence what’s in patient’s chronic disease management plan includes:
Medical history
Family history
Genetic predispositions
Whether smoke tobacco
How much alcohol drink
The work does and other responsibilities
The stresses and complications in life
Comorbidities (the other diseases have)
The patient’s chronic disease management plan lays
out the recommended treatments for his/her
conditions and a schedule of testing and reviews.
This detailed approach to care ensures that the
plan is kept up-to-date and responsive to
changing needs.
This suggest seven core principles and a set of
actions that will support a renaissance in, and a
positive future for, primary care.
The seven principles are1) Health care must be organized to serve the
needs of patients;
2) the goal of primary care systems should be the
delivery of the highest-quality care as documented
by measurable outcomes;
3) information and information systems are the
backbone of the primary care process;
4) current health care systems must be
5) the health care financing system must support
excellent primary care practice;
6) primary care education must be revitalized, with
an emphasis on new delivery models and training
in sites that deliver excellent primary care; and
7) the value of primary care practice must be
continually improved, documented, and
-Wholesome diet is absolutely essential for health
& wellbeing. First have to acknowledge the fact
that good health is all about taking charge and
doing what’s right for body.
-Eat more of green veggies, fresh fruits, calcium &
fiber rich foods
-Switch to whole grain/multi grain flour.
-Reduce your portion size and eat at regular
intervals (every 2 hours)
-Eliminate or at least try to limit the consumption of
oily food
-Replace junk food with healthy snacks
-Drink plenty of water
-Take the stairs instead of lift & elevators
-Walk from the bus stop to your home/office
-Take your dog out for a walk daily
-Do household chores for at least 30 minutes daily
-If you have kids at home, play with them and burn
some calories
-Always take a short walk after your meals
Heart care
1/3rd of deaths caused by heart diseases can be
avoided merely by staying away from cigarettes &
alcohol. Both, alcohol and nicotine are known to
cause severe damage to the blood vessels which
automatically doubles the risk of atherosclerosis
and blood clotting. By giving up these health
damaging habits, you will not only be able to keep
lifestyle diseases at bay but also develop higher
energy levels, younger looking skin and improved
lung capacity.
Body weight
Make sure you keep a close watch on your body
weight. Extra weight especially near the tummy
has been linked with cardiovascular deaths.
People who are obese & overweight are also at
risk for many more serious health conditions like
sleep apnea, diabetes and cancer. Manage your
weight by eating low-calorie, fat-free food and
incorporate some form of workout in your daily
Fat food
Anything in excess is bad for health. High intake of
Sugar, Salt, & Oil can lead to serious
repercussions in the form of diabetes, blood
pressure and heart problems (due to high
cholesterol). Cut down the usage of these 3
ingredients in your food.
Health check-up
Take good care of your body – it’s the only place
you live in. Periodic health check-ups can offer a
thorough analysis of your current health status.
Moreover, it also helps in early diagnosis and
timely treatment of any kind of illness. Schedule an
appointment for a comprehensive health check-up
once in every 6 months.
CDMP for improving
The CDM Programme aims to improve the health
and well being of patients living with specific
chronic diseases-Type 2 diabetes, Asthma, COPD
and Cardio vascular disease. It is provided by all
Centric Health GP Practices to ensure patients
conditions are actively monitored to improve
management of their conditions.
CDMP important
Conditions such as asthma and diabetes require
regular monitoring to prevent the disorders from
progressing to life-threatening levels. Chronic
disease management, therefore, is essential to
both improving health outcomes of poor individuals
and containing costs in the United States health
care system.
Benefit of a patient
-Structured reviews of chronic disease with GP or
practice nurse
-A personalised care plan developed and agreed
with GP
-Regular reviews of care plan and medication
-Opportunities for structured education and selfmanagement support
-Early detection of any new conditions may
-Early detection of complications in condition(s).
-Care in community, close to home.
-High prevalence of chronic diseases and
conditions in older adults create huge burden on
individuals and healthcare system.
-CDMP could reduce the burden by enhancing self
efficacy and motivation, and improving health
status of those with chronic diseases.
-Training lay leaders could be cost-effective and
sustainable means of promoting self-management
concept in community.

Schedule an Appointment

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