Chronic Disease Management

These programs:

• Assist with coordination of health care for health department patients with certain  medical conditions
• Provide education and case management aimed at improving quality of care and life
• Promote self care for individuals by preventing or minimizing the effects of a chronic disease
• Pre-screen individuals seeking Medicaid long term and nursing facility care and certain Medicaid waivers

Programs Offered

Diabetes Case Management offers outreach, assessment, planning, service coordination, monitoring, evaluation, and advocacy to the multiple changing needs of Peninsula Health District clinical services patients and their families. The goal of diabetes case management is to improve quality of care and life.

Chronic Disease Self-Management Program teaches lay leaders to conduct workshops in community settings such as senior centers, churches, libraries and hospitals. The program, developed by Stanford University, is facilitated by two trained leaders, one or both of whom are non-health professionals with a chronic diseases themselves. People with different chronic health problems attend together. It teaches the skills necessary for the day-to-day management of chronic diseases. Classes are highly participative, where mutual support and success build the participants’ confidence in their ability to manage their health and maintain active and fulfilling lives.

Stanford University Chronic Disease Self Management Program

Medicaid Pre-Admission Screening

Virginia’s Department of Medical Assistance Services requires an evaluation of medical, nursing, developmental, psychological and social needs of individuals believed to be in need of or at risk of nursing facility admission if the individual is seeking Medicaid funding.  A public health nurse from the local health department and a social worker from the local department of social services visit the patient at home to assess if the person is in need of nursing facility care.  This information is used to determine whether an individual meets criteria for Medicaid funded nursing facility services or community based care.  A Medicaid application must be filed with the local department of social services where the person resides in Virginia and the individual must be deemed Medicaid eligible to receive services.
 
This program also evaluates individuals seeking Medicaid Waivers for:

• Program for the All inclusive Care of the Elderly (PACE).  This program provides all Medicaid covered services, primary medical and specialty care, nursing, social work, personal care, in-home supportive services, restorative therapies (occupational, physical, and speech language pathology), meals and nutritional care, transportation, and recreational therapy.
• Elderly or Disabled with Consumer Direction Waiver (EDCD) for personal care aide services, adult day health care, respite care, and personal emergency response system
• Human Immunodeficiency Virus Waiver for services providing personal care, case management, respite care, nutrition, private duty nursing, etc.
• Technology Assisted Waiver for services providing personal care, private duty nursing, respite care, environmental modification and assistive technology

Department of Medical Assistance Services – Long Term Care

Virginia Department for the Aging No Wrong Door

Call (757) 594-7426 for more information.