Chronic Care Management


Chronic Care Management at Pender Community Hospital 

At Pender Community Hospital and Medical Clinics, chronic care management is all about offering whole, well-rounded care for our patients. To do this, we use an approach where primary care providers and nurses serving as health coaches team up to work alongside patients, providing them with a high level of support to not just effectively manage their health conditions, but thrive while living with them. 

How Our Team Approach Works
Primary care providers serve as the lead when it comes to chronic care management for patients. They have that personal connection with them and really understand their healthcare needs. However, as the amount of testing, screening, referrals and prescriptions increases, it’s often difficult for a provider to do everything alone. That’s when health coaches step in to help.   

Health coaches are nurses who are specifically trained to give patients additional support, encouragement, and assistance. They are the true difference makers and provide extra nursing assistance to help manage chronic diseases by: 

  • Working as the communication agent between patients and their physicians
  • Coordinating patient care through the scheduling of appointments, lab work, and other procedures
  • Touching base with patients between appointments as needed 
  • Offering extra help, guidance and education to patients 
  • Providing extra support for the primary care providers

The work that health coaches do allows there to be a free flow of information between primary care providers and their patients. The result is a very personalized approach to healthcare where strong relationships are the foundation for patients living happy, healthier lives. 

Chronic Conditions We Can Help Manage
Using our team approach, we can help manage a number of different chronic health conditions. Examples include: 

  • Diabetes 
  • Heart disease
  • Asthma
  • Cancer
  • Obesity
  • Osteoporosis
  • Arthritis
  • If you would like to connect with one of our coaches, call 402-385-3033, option 3.