Treatment goals
Chronic care management program 2019
Diabetes mellitus A1C less than 7.0%
Fasting capillary glucose
80-120 mg/dl
Non fasting capillary
glucose less than 180
mg/dl
Diabetic Reducing current
polyneuropathy symptoms
Properly care for your feet
with massage on foot
Reduce rates of
ulceration
Bilateral diabetic Reduce the risk of
retinopathy blindness
Comprehensive dilated
eye exam per year
Prevent risk of develop
PDR
Diabetes mellitus Manage blood glucose
with gastroparesis levels
Correct use of insulin
Prevent feeding tubes
and intravenous feeding
Hypoglycemia Monitor blood glucose
levels
Prevent symptoms of
shakiness, tachycardia,
Home blood sugar Strength training in Avoid heating pads Patient was
testing diet and exercise and always to wear educated about
Monitor urine albumin Ways to manage shoes when walking signs of
to serum creatinine for high blood Physical activity neurological
renal failure pressure and high Follow the manifestations
Prevent feet changes cholesterol were prescribed diet No numbness,
of temperature, given It was instructed on sensitivity to pain
pulses, and sensation Assess for signs of use moisturizers present
hyperglycemia and increase Balance and
physical activity coordination
conserved
Assess diabetic High control of
polyneuropathy blood sugar levels
symptoms: loss of Keep balance and
sensation, incorrect coordination
perception of tactile Prevent foot
sensations or pain on problems, such as
skin friction ulcers, infections,
deformities, and
bone and joint pain
Prevent injuries
Instruct patient to
have simple
carbohydrate available
 palpitations, drowsiness
Provide simple
carbohydrate
Prediabetes Reduce caloric intake and
glucose disposal
Reduce insulin resistance
Prevent progression to
DM
Hypertension Blood Pressure less than
130 systolic and 80
diastolic
Improve adherence to
DASH diet
45 minutes exercise daily
Hyperlipidemia Total cholesterol less than
200
LDL less than 100
Triglycerides less than
150
Hypertriglyceridemia Patient was instructed
about lifestyle
modifications such as
diet, exercise, weight
reduction, no smoking, no
alcohol
Hypothyroidism Reduce metabolic
demands
at all times
Encourage self-
monitiring of blood
glucose levels
Maintain BP within Improve adherence Demonstrate stable
individually acceptable to current HTN cardiac rhythm
range protocol Participate in
Participate in activities DASH diet activities that
that will prevent future Be aware about reduce BP
cardiovascular alarm symptoms Blood Pressure less
complications such as severe than 130 systolic
Decrease sodium headache, chest and 80 diastolic
intake in diet pain, visual or
speech alterations
Prevent heart attack Foods with low Reduce the intake
or stroke cholesterol and of saturated fat,
Total cholesterol less saturated trans fat trans fats, and
than 200 Limit the intake of cholesterol
Moderate physical red meat and dairy Colorful array of
activity at least 30 products made with vegetables, be high
minutes 5 times per whole milk in fiber, and whole
week Increase physical grains
activity Regular servings of
fish, nuts, and
legumes are
recommended
Reduce low-density
lipoprotein (LDL)
levels
Prevent pancreatitis
Maintain TSH levels in
normal range
 Support cardiovascular Education about
function possible side effects
Prevent complications of levothyroxine
overdose
Control weight
changes
Hyperthyroidism Prevents undue fatigue;
reduces metabolic
demands
Restrict salt intake if
indicated
Monitor daily food intake
Thyroid cancer Oncology following Look for neck lumps
Thyroid-stimulating or breathing troubles
hormone (TSH) swallowing
suppression therapy
Hypoparathyroidism Relieve symptoms
Correcting the
hypocalcemia
Monitor phosphorus
levels
Chronic kidney Keep GFR stable Target BP goal of A lower protein diet Lifestyle changes to
disease Decrease protein intake <140/90mmHg to minimize waste ensure to remain as
Increase fluids intake Reduce both renal products is healthy as possible
and cardiovascular recommended No evidence of fluid
morbidity Avoid NSAIDs retention
Minimize proteinuria Maintain regiment
adjusted to renal
doses
ESRD Maintenance of fistula Continue in control by Control electrolytes
Control weight changes Nephrology (sodium,
Be aware about alarm Control daily liquid potassium,
symptoms of Uremia intake phosphorus)
Maintain updated Adjust medications Limit sodium intake
immunization regimen with renal dosage
Anemia in renal Stop decreased RBC
disease destruction and blood loss
Anemia therapy of
erythropoiesis-stimulating
agents
 Control hypertension
Anemia in chronic Hb > 13g/dl
disease Prevent symptoms of
myocardial ischemia
Diet food rich in iron
Anemia secondary Vitamin B12 or folic acid
to vit B12 deficiency supplements if prescribed
Correct the shape of the
red blood cells
Stop the decrease of
hemoglobin levels
Major depression Improve social and family
relationships
Increase physical health
behaviors
Perform Outdoor activities
COPD Avoid hospitalization
Decrease cough and
shortness of breath
Keep rate, rhythm, depth,
and effort of breaths
adequately
Asthma Prevent chronic
symptoms such as
coughing or shortness of
breath
Prevent repeated asthma
attacks
Identify and avoid triggers
as possible
Avoid exertional Avoid fatigue and
discomfort or dyspnea lack of energy.
Inability to maintain
usual level of physical
activity denied
Determine presence Identify symptoms Instruct patient in
and degree of suicidal like mood disorder, coping strategies
risk hallucinations, (e.g., assertiveness
Monitor for medication substance abuse, training, impulse
side effects and grief control)
desired outcomes Involve patient in Provide information
Improve access to planning his/her about what
mental health services own treatment community
resources and
outreach programs
are available
Monitor rate, rhythm, Note chest Avoid dyspnea and Correct usage of
depth, and effort of movement, events that inhalation therapy
respirations watching for decrease and Improve usage of
Improve patient’s symmetry, use of worsen it aerochamber
ability to cough accessory muscles Respiratory Improve oral
effectively Reduce patient therapy, as hygiene
respiratory appropriate
secretions
Prevent repeated Avoid contact with
asthma attacks smoke, pets or
Clean home regularly occupational
Cover nose and triggers
mouth if it's cold out
Weight lose
 Warm fluids to drink, as
appropriate
Use techniques for using
medication (e.g., inhaler,
nebulizer)
Sleep apnea Management by
pulmonology
Weight loss encouraged
Use CPAP with
Pulmonology instructions
CAD Avoid: A lot of red meat, Follow up with
palm and coconut oils, Cardiology as directed
sugary foods and Avoid episodes of
beverages angina
Increase: Fish high in Compliance with anti-
omega-3 fatty acids, such platelet therapy as
as salmon, tuna, and secondary prevention
trout, about twice a week
and Fruits, such as
apples, bananas,
oranges, pears, and
prunes
Maintain a BMI Between
18.5 and 24.9
CHF Maintain blood pressure Fluid control to Maintain blood
between normal ranges, prevent fluid overload pressure between
less than 140 systolic Frequent use of normal ranges
Avoid CHF worsening diuretics Avoid
symptoms (cough, Blood pressure control hospitalization and
irregular heartbeat) rehospitalization
No symptoms of due to pulmonary
pulmonary edema edema
Diastolic heart Avoid Hospitalization Maintain EF
failure Improve Exercise Control BP
Tolerance Prevent fluid overload
Atrial fibrillation Compliance with Compliance with
anticoagulation therapy. Warfarin regimen
Prevent S/E: Bleeding, Consider medication
falls. dosage
 Maintain sinus rhythm Regular measurement
Avoid major of PT/INR
cardiovascular
complications (cardiac
embolism)
Peripheral vascular Address each risk factor Avoid standing or
disease that led to the sitting for long periods
development of PVD Physical activities
Abstinence from cigarette Improve muscle tone
smoking Compression
Increase the walking time stockings
to reduce claudication
Atherosclerotic Avoid risk of bleeding
cerebrovascular associated
disease Prevention of an
embolism
Cholesterol controlling
medications
Osteoporosis Prevention of fractures Increase the amount
Increase weight-bearing of roughage or fiber in
and muscle-strengthening the diet
exercise Instruct recommended
Improve calcium levels daily intake for
calcium
Increase exposure to
sunlight
Limit caffeine intake
Osteopenia Stop the loss of bone
density
Improve and sustain
vitamin D levels
Walking, stair climbing,
dancing
Alzheimer disease Improve quality of life Provide positive Label drawers, use Allow patient the
Decrease disease reinforcement and written freedom to sit in a
progression feedback for positive reminders notes, chair near the
behaviors pictures, or color- window, utilize
Eliminate or minimize coding articles to books and
sources of hazards in assist patients magazines as
the environment Maintain a regular desired

Parkinson disease Reduce Parkinson’s
disease symptoms
Maintain activities of daily
living
Physical therapy
Dementia Environmental
modifications Caregiver
training Memory clues
Minimizing background
noise and noise
reverberation
BPH (benign Avoid urinary retention
prostatic Control symptoms
hyperplasia) Avoid progression
daily schedule Use a rather low
routine  voice and spoke
slowly in patients
Encourage increase in Assess the
intake of fluids up to 3- patient’s ability to
4 L/day speak, language
Assess patient for deficit, cognitive or
depressive behaviors, sensory impairment
causative events, and Avoide presence of
orient patient to reality psychosis, and/or
as warranted other neurologic
disorders affecting
speech.
Caregiver refers a Psychotherapy
functional patient, with Increase safety and
support to daily comfort
activities but going Reduce severity of
well Caregiver training problematic
was given focused on behaviors
providing the requisite
knowledge about
dementia and specific
strategies including
problem-solving,
communication
techniques and
simplification
approaches to
manage daily care
challenges
Encourage patient to Fluids intake up to Promote bedrest Encourage patient
void every 2–4 hr and 3000 mL daily, with head elevated to void every 2–4 hr
when urge is noted within cardiac Monitor electrolyte Prevent, bladder
Prevent mucosal tolerance, if levels, especially distension, renal
irritation, bladder indicated sodium colic urinary
distension, renal colic Use of sitz baths, Prevent infection
urinary infection warm soaks to complications as Fluids intake up to
perineum loudy, odorous 3000 mL daily
Avoid spicy foods, urine, diminished
coffee, alcohol, urinary output,
 long automobile inability to void
rides
Chronic prostatitis Decrease recurrences by
diminishing urinary
obstruction
Reduce inflammation
Eradicate the infection
Overactive bladder Avoid spicy foods, Evening fluid Kegel exercises
caffeine and carbonated restriction and daytime Empting bladder
drinks bladder training before bed time
Kegels exercises Avoid spicy foods, Restrict fluid intake
Schedule toilet trips caffeine and at night in order to
carbonated drinks avoid nocturia
Schedule toilet trips
Cystocele Stop prolapse worsening
Exercises that strengthen
pelvic floor muscles
Hydronephrosis Restart the free flow of
urine
Decrease the swelling
and pressure that builds
up
Minimize pain and
prevent urinary tract
infections
Urolithiasis Prevent recurrent stone
formation
Prevent further growth of
any existing stones
Prevent extrarenal
complications
GERD Decrease acid reflux Loss weight Eliminate the
Pain relief Eat smaller meals underlying causes
Elevate the head of the Decrease acid reflux of the disease
bed Pain relief Diet modification,
rest, stress
reduction
Consider switching
pain relievers
 Constipation Improve symptoms and High fiber diet
restore normal bowel Stimulate gut mobility
function
Accelerate colonic transit
Facilitate defecation
Diverticulosis Increase fiber diet
Get plenty of fluids daily
Relieve abdominal pain
Chronic gastritis Patient is instructed on
avoid aspirin, ibuprofen or
naproxen.
Contact us if present
Epigastric pain that does
not go away.
Black or tarry stools.
Vomiting with blood
Colon polyps Regular colonoscopy
Healthy lifestyle
Prevent higher-risk
features
Fatty liver A 10% reduction in body
weight
Prevent progression of
NAFLD to NASH and
cirrhosis
Diet low in saturated fats
and high fiber
Angiodysplasia of Treat bleeding
small intestine hemodynamic stability
Avoid recurrence of
symptoms
Hepatitis C Delay progression to Follow up with
cirrhosis and HCC gastroenterology
Improve survival Decrease viral load
Reduction in development Compliance with
of resistance pharmacological and
Normalize liver function non-pharmacological
treatment
Cirrhosis Slow or reverse Educate about alarm
 progression of the liver symptoms: edema in
disease the legs or in the
Prevent and treat abdomen
complications Do not eat raw fish or
Determine seafood
appropriateness and Low sodium diet
optimal timing for liver Prevent ascites
transplantation Follow diet
recommendations
Avoid jaundice
Alcohol abuse Decrease alcohol intake Reach abstinence with
Control abstinence otherwise good health
syndrome symptoms and support
Refer to support group Reduce the risk of
develop alcohol
withdrawal (AWS)
Prevent life-
threatening
complications related
Glaucoma Decrease intraocular
pressure
Routine pressure
measurements
Inspection of the optic
nerve and visual field
Bilateral cataracts Improving vision.
Helping you return to
work, leisure, and other
daily activities.
Presbyopia Clear binocular vision and
good ocular health
Regular follow/up
Allergic rhinitis Resolution of symptoms Remove mucus from
Adequate use of nasal the nose
spray Avoid pollen and/or
environmental
exposure
Contact if presence of
fever
 Hearing loss Getting a hearing device,
such as a hearing aid
Speech Therapy
Joining support groups
Vitamin D deficiency Normalize vitamin D Keep levels above 30
levels Increase vitamin D
Follow the consumption in diet
supplementation Physical activity in
recommendations regular basis
Lessen the risk for
fractures and falls
Carpal tunnel Wear a wrist sprint
syndrome Avoid activities that may
be causing symptoms
Physical therapy
Osteoarthritis Strengthening exercises Patient was instructed Pain relief
around OA-affected joints on the importance of Improvement of
Reduces the weight adequate exposure to functional status
excess sunlight to prevent Unloading in
Slow progression of the vitamin D deficiency certain joints *eg,
disease Assess patient’s knee, hip*
functional ability for
mobility and note
changes
Rotator cuff Resting the injured
tendinitis tendon
Decreasing inflammation
Correct imbalances that
caused stress on the
injured area

Baker cyst Reduce pain and swelling

Icing - compression wrap
and crutches
Strengthening exercises
for the muscles around
the knee
Chronic pain Use therapeutic Continue under care
syndrome communication strategies by Pain management
to acknowledge the pain Avoid symptoms
 experience progression
Explore with patient Follow therapy as
factors that directed
relieve/worsen pain
Use pain control
measures before pain
becomes severe
Spondylolisthesis Alleviate irritation and
swelling
Physical therapy
Take a break from sports
Thoracic Reduce spams and
spondylosis chronic muscle tension
Hot and cold therapy
Gentle hamstring
stretching
Chondrocalcinosis Relieve the symptoms of
pain and swelling
Cold packs
Sacroiliitis Restore the joint's normal
motion
Alleviate pain
Ice applied in 15 to 20
minute intervals
Mid back pain, Exercise to stretch and
chronic strengthen back muscles
Practice a good posture
Rheumatoid arthritis Prevent and control joint Put disease in Joint function,
damage remission mobility and quality
Prevent loss of function Prevent joint and of life preserved
Maintain quality of life organ damage Physical activity
Avoid or minimize Improve physical and maintain a
adverse effects function and overall healthy weight was
well-being recommended
Patient education
and support given
Gout Protect against further Rest the affected Prevent Control
attacks joint(s) complications such inflammation
Prevent flares and Use ice to reduce as destructive Relieve pain
 disease progression swelling arthropathy, tophi Reduce disability
Lower serum urate Take short-term or renal stones associated with the
sufficiently to deplete the medicines at the first condition
total body urate pool sign of a gout attack Prevent commonly
associated entities:
obesity,
hypertriglyceridemia
and HTN
LUPUS Lowest possible disease Prevent flares
activity Avoid adverse effects
Prevent organ damage from medications
Improve quality of life Minimize organ
damage
Sjogren syndrome Improve dryness
Normalize autoimmune
responses
Prevent malignancies
Psoriasis Help reduce inflammation
Reduce the activity of the
immune system
Help flay skin and unclog
pores / Smooth the skin
Schizophrenia Assess if incoherence in
speech is chronic
Keep environment calm
and free of stimuli as
possible
Perform deep breathing
exercise in frequent
periods per day
Bipolar disorder Reduce the risk of injury
self directed/other
directed
Take short voluntary rest
periods during the day
Avoid symptoms of lithium
toxicity (diarrhea, nausea,
tremor)
Epilepsy Control of seizures
regardless of side effects
 Lead lifestyles consistent
with patient capabilities
Evaluate patient risk
factors for recurrence
Mental retardation Develop the patient's
potential to the fullest.
Improve social skills to
help the person function
as normally as possible
Breast cancer Prolong survival
Restricting treatment-
related toxicity
Symptom relief and
quality of life
Thrombocytopenia Prevent disability caused
by bleeding
Avoid severe cuts or
accidents
Try to avoid contact with
toxic chemicals and
alcohol
Obesity Self-monitoring of caloric
intake and physical
activity
Goal setting
Stimulus control