Special Programs

Chronic Disease Management Program

The Chronic Disease Management Program’s goal is to improve the healthcare outcomes of patients with chronic conditions by managing patient outcomes through the utilization of clinical information systems and clinic-based interventions.

The program is comprised of a Diabetes Program, a pediatric and adolescent Asthma Program, and most recently a Hypertension program. These programs are overseen by a Nurse Program Manager. Through the use of the clinic’s electronic health record (EHR), we provide reminders to our health care providers at the patients’ clinic visits and track 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, Integrated Behavioral Health, Health Education, Adult Medicine and Endocrinology. Additionally, nurse case management and Diabetes education is available to patients enrolled in the program.

The Asthma Program provides patients and their family with Asthma education and case management. The Nurse case manager 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 referrals to the parents.

The Hypertension Program provides patients with the tools necessary to understand and manage their blood pressure. This is done through case management, regular monitoring and counseling patients on the Dietary Approaches to Stop Hypertension (DASH) diet.

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.