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Mailing Address:
P.O. Box 939
La Marque, TX 77568

Strategic Plan header Picture Phone: 409-938-2401
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PRIORITY #5: MANAGEMENT OF CHRONIC CONDITIONS
Improve the identification and management of chronic conditions such as high blood pressure, heart disease, diabetes, asthma, depression, etc.
GOAL I Establish official 4C’s Standards of Care.
Objective One: Develop and implement clinic practice guidelines for chronic conditions such as high blood pressure, heart disease, diabetes, asthma, and depression.
Activities:

  • Outline the categories of a comprehensive clinic practice guideline that should be covered.
  • Research evidence based guidelines from US Preventive Health Services and other professional association groups.
  • Prepare written clinic practice guidelines and consistent patient education materials and review with the Clinic Leadership Team.
  • Train all appropriate staff on the clinic practice guidelines.
  • Make the guidelines readily accessible such as posting on the intranet.
Objective Two: Develop and implement a Quality Insurance Monitoring Program.
Activities:

  • Establish periodic monthly reports for the Clinic Leadership Team and quarterly reports to the 4C’s Governing Board.
  • Report outcome and process measures to the 4C’s Governing Board.
GOAL II Identify and develop clinic guidelines for other identified priority health conditions.
Objective One: Develop criteria for identification of priority health conditions.
Activities:

  • Use existing clinic and county data to identify other chronic health conditions.
  • Identify chronic health conditions by level of impact on 4C’s patients.
  • The Clinic Leadership Team selects the health condition by established criteria.
  • Develop clinic practice guidelines for identified chronic health conditions.
GOAL III Integrate chronic health conditions activities with other Health District programs.
Activities:

  • Assess and identify internal referral opportunities across all Health District programs.
  • Identify opportunities for additional referrals to other Health District programs.
  • Assess current referral processes across Health District programs.
  • Monitor referrals and other activities.