Variety Care’s Chronic Disease Management Clinic (CDMC) was created to address the unique needs of patients with long-term medical conditions requiring significant patient self-care.

CDMC works with patients who have been identified as “at risk” due to their status as uninsured, underinsured, or “high utilizers” of health care services who do not have a medical home.

Variety Care, in collaboration with St. Anthony Hospital, applies the tenants of Chronic Disease Management and combines them with  Directed Care Coordination. These efforts help improve patient health outcomes, health behaviors, and ultimately reduce health care utilization.

Although the Variety Care CDMC is in its early stages, we are making significant progress toward solving the unique problems faced by “at risk” patients.

Our efforts begin shortly after an at risk patient is discharged from the hospital or Emergency Room. St. Anthony Hospital sends patient information to Variety Care CDMC, and a CDMC nurse contacts the patient within two days to begin identifying the best way to meet the patients needs efficiently.

Patients receive assessments and interventions from multiple disciplines including the PCP, Care Coordinator, Registered Dietitian, and Social Services. The CDMC identifies and monitors patients’ needs through frequent clinic appointments and phone assessments. By working individually with each patient and by ensuring that their needs are met, patients trust us to provide appropriate care for them outside the hospital.