Ammonoosuc Community Health Services, Inc.
Chronic Disease Management
Chronic Disease Management

Chronic Disease Management

ACHS has been involved in improving the quality of care for our patients with chronic diseases by carefully monitoring data about their health since 1998. We use the well-recognized “Chronic Care Model” and “Plan, Do, Study, Act” processes. A team meets monthly to analyze agency wide data and discuss and create ideas to improve care. The ideas are tested, evaluated, and implemented agency wide. Ideas have included the creation of patient education materials such as dietary advice for high cholesterol; tools to support providers such as computer alerts that remind them when patients are due for important tests; or the use of patient navigators to help patients overcome social and economic barriers to achieving better health.

We monitor outcomes for depression, diabetes, asthma, heart disease, cancer prevention, and immunizations amongst others.

We have worked closely with the Institute for Health Care Improvement and Bureau for Primary Health Care in conjunction with leading centers throughout the nation. Our work has been nationally recognized and we have been selected as one of 26 of the highest performing health centers in the nation.

Through commitment to our community and constant system improvement, our providers are given the tools to help each patient obtain the best health possible.


Downloadable Materials