Special Programs

Chronic Disease Management Program

The Chronic Disease Management Program’s goal is to improve the healthcare outcomes of patients with chronic conditions through disease registry maintenance and clinic-based interventions.

The program is comprised of a Diabetes Program and a pediatric and adolescent Asthma Program which are overseen by a Nurse Program Manager.  At the close of 2008, over 650 patients with diabetes and 120 with asthma were enrolled in the Disease Registry.  The Disease Registry provides reminders to providers at the time of a patient’s clinic visits and tracks patient progress to develop clinic-wide interventions.  These measures improve PCC’s efficiency and quality of medical care for chronic disease patients.

The Diabetes Program engages a multidisciplinary team of health professionals at the Clinic who meet bi-monthly to discuss and develop clinic-based interventions.  This team includes members from the following departments: Nutrition and Health Psychology, Integrated Behavioral Health, Health Education, Adult Medicine and Endocrinology.  Additionally, nurse case management and health education counseling is available to patients enrolled in the program.

The Asthma Program provides patients with resources such as the Asthma Toolkit and access to a Health Educator. The Health Educator provides asthma education and does regular phone follow-up with patients.  The Health Educator and the patient create an asthma action plan to help the patient and family manage the patient’s asthma. The Clinic also provides smoking cessation services to the parents.

The Chronic Disease Management Program is a member of the Central Texas Diabetes Coalition, the Central Texas Asthma Coalition, and the Austin Tobacco Prevention and Control Coalition.  PCC is a site for University of Texas at Austin School of Nursing clinical practicums.