Chronic Disease Management Program

At People’s, managing chronic conditions is a team effort. The Chronic Disease Management Program works to improve the healthcare outcomes of patients with Pre-Diabetes, Diabetes, Pediatric/Adolescent Asthma, and Hypertension.

The program is managed by Elizabeth Alvear, MSN, RN, CDE and utilizes the clinic’s electronic health record (EHR) to track patient progress and assist providers in developing clinic-wide interventions. These measures improve People’s efficiency and quality of medical care for patients with a chronic disease. 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.

Diabetes & Hypertension

The Chronic Disease Management Program provides patients with Diabetes Self-Management Education (DSME), Pre-Diabetes, and Hypertension education in a one-to-one and group setting. Registered Nurse (RN) Chronic Disease Care Coordinators visit with patients at the time of the office visit to assess any barriers to their care, deliver Diabetes and Hypertension survival skills education, help facilitate internal referrals, and participate in the creation of a plan of care along with the provider.

Case management is continued by the RN Care Coordinator either over the telephone or in person in between office visits with the provider. Telephone follow-up on self-care behavior is completed with all patients who receive Pre-Diabetes education by a specially trained Medical Assistant. Regular monitoring to ensure adherence to the plan of care is done for all patients who participate in the program.


The Asthma Program provides pediatric and adolescent patients and their family with asthma education and case management. The case manager and patient create an Asthma Action Plan to help the patient and family manage the patient’s condition. The clinic also provides smoking cessation referrals to the parents.

People’s invites you to learn more about Diabetes prevention and treatment.

Whether you or a loved one has just been diagnosed with Pre-Diabetes or it’s been years since having a diagnosis of Diabetes, it is never too late to take action to protect your health. The clinic delivers a wide array of resources for patients with Diabetes in our Chronic Disease Management Program. Here are some that we recommend.

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