Chronic Disease Management

Service Description

A comprehensive, lifespan-focused program (ages 21–99) for males and females, closing all major gaps in chronic care through: Early detection – Age- and gender-tailored annual screenings (BP, lipids, glucose, cancer, mental health) Personalized plans – Evidence-based management of diabetes, hypertension, CVD, COPD, arthritis, osteoporosis, obesity Lifestyle support – Nutrition, exercise, smoking cessation, and stress coaching Continuous care – Telehealth monitoring, medication adherence, and specialist coordination Equity focus – Culturally sensitive services in English and Creole, addressing access barriers