Chronic Conditions

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Care Manager Interventions for Chronic Diseases

The information contained within these chronic disease pages is designed to:

  • Help care managers assist patients who suffer from specific chronic conditions
  • Provide a framework for care management interventions
  • Present various resources dedicated to the education of both the care manger and the patient
  • Provide quick access to tools to be used in patient care setting

Each chronic disease page includes the following:

  • Disease definition
  • Evidenced based guidelines
  • Action plan
  • Care management interventions
  • Patient interventions
  • Care management quick tools
  • Patient handouts
  • Care management learning resources


Common Definitions:

  • Evidenced Based Practice: “The conscientious, explicit and judicious use of current best evidence in making decisions about the care of the individual patient. It means integrating individual clinical expertise with the best available external clinical evidence from systematic research."
  • Action Plan: An action plan is a document that lists what steps must be taken in order to achieve a specific goal. The purpose of an action plan is to clarify what resources are required to reach the goal, formulate a timeline for when specific tasks need to be completed and determine what resources are required.
  • Care Management Interventions: Interventions for specific areas of concern when working with patients with chronic conditions. This information is intended to be a starting point for care mangers working with patients with chronic conditions.
  • Care Management Learning Resources: Resources providing more in depth information on various areas of heart failure
  • *It is important to always check with your practice regarding the use of interventions, protocols and guidelines.

Chronic Disease Pages Links:

Heart Failure





Childhood Obesity

Adult Obesity