Chronic Disease Management
The CCWV delivery model is highly suitable for the health needs of the community. Our model provides for a complete range of on-site services for comprehensive patient care. The mix of medical providers, which includes physicians, certified family nurse practitioners, and certified physician assistants, provides the specialized knowledge and resources needed for treating patients at all lifecycles, including pediatrics, geriatrics, and all other aspects family medicine. The delivery model provides a number of conveniently located, well-staffed access points that are open year-round, with the hours of operation (including evenings and weekends) to allow for a wide variety of individual work and family schedules.
In addition to a quality staff of medical providers, CCWV's nurses serve within the patient care team, providing assessment and education so patients better understand their illness and what they can do to help themselves. These Care Managers and the patient’s medical provider work closely together to give the patient the best care management possible. As part of this expanded care management assessment, the health history of all patients is reviewed to assure that each has been screened for chronic conditions including high blood pressure, high cholesterol, depression, weight management, physical activity, and asthma. Other risk factors, such as pregnancy, co-morbid conditions, or family history of disease, are also assessed.
In addition to a quality staff of medical providers, CCWV's nurses serve within the patient care team, providing assessment and education so patients better understand their illness and what they can do to help themselves. These Care Managers and the patient’s medical provider work closely together to give the patient the best care management possible. As part of this expanded care management assessment, the health history of all patients is reviewed to assure that each has been screened for chronic conditions including high blood pressure, high cholesterol, depression, weight management, physical activity, and asthma. Other risk factors, such as pregnancy, co-morbid conditions, or family history of disease, are also assessed.
The Patient-Centered Medical Home
“ We are working hard to improve the care we give, while also reducing costs.”
At Community Care of West Virginia we will ask you to choose a personal provider. We will enter your information into our Electronic Health Record (EHR), so whenever possible, we will schedule you with your personal provider. We know that it is important that your personal provider know you and your family. Your personal provider, together with your healthcare team, provide and coordinate evidence-based, whole person health care for all stages of life including, prenatal, preventive, acute, chronic, and end-of-life care.
We know that the health care system is complex and confusing (e.g., specialists, hospitals, nursing homes, community services). We are dedicated to coordinating your care. We believe that our patients should never feel “lost in the system”. You will have a dedicated Care Team who will help to arrange services for you outside of our health center (specialist visits, testing etc.) and ensure that we receive your reports/results on your visits. The Care Team is assigned to you to help you achieve your agreed upon treatment goals. Our physicians lead teams of skilled professionals that work together to meet your health care needs. Visits are coordinated across multiple health care settings with multiple staff as necessary to improve access and reduce costs.
We know that the health care system is complex and confusing (e.g., specialists, hospitals, nursing homes, community services). We are dedicated to coordinating your care. We believe that our patients should never feel “lost in the system”. You will have a dedicated Care Team who will help to arrange services for you outside of our health center (specialist visits, testing etc.) and ensure that we receive your reports/results on your visits. The Care Team is assigned to you to help you achieve your agreed upon treatment goals. Our physicians lead teams of skilled professionals that work together to meet your health care needs. Visits are coordinated across multiple health care settings with multiple staff as necessary to improve access and reduce costs.
