Managing Chronic Conditions in the Community | MedStar Health

Managing Chronic Conditions in the Community

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In the video above Living Well program participant, Nicole Glover Wright and lay leader Janis Perry speak about their experiences during the program.

Living Well: Chronic Disease Self-Management Program

Through the 2015 Community Health Needs Assessment, MedStar Health identified chronic disease prevention and management as a strategic area of priority and the need for evidence-based programs to address chronic disease in the community. In 2017, MedStar launched its first system-wide evidence-based program, Living Well—a seven-week health education and behavior change program focused on chronic disease self-management for people living with one or more chronic diseases. Participants can register online or by phone, and MedStar providers can directly refer patients to the program through a referral link in the Electronic Health Record.

Living Well is led by trained lay leaders who help participants with chronic conditions, such as heart disease, diabetes and cancer, learn how to manage their condition and improve their health and quality of life.

In 2017, MedStar trained more than 70 lay leaders to deliver the Living Well program in communities surrounding MedStar’s 10 hospitals that are underserved or disproportionately affected by chronic conditions.

“We know that chronic conditions are impacting both our patients and the community at large, and are a significant driver to healthcare utilization patterns and costs,” says Dawnavan Davis, PhD, assistant vice president of MedStar Community Health.

The program educates participants through homework exercises, behavior modification and the creation of self-management plans. Approximately 200 individuals have enrolled in the program since it started.

“In general, people who complete the program report better self-management, significant weight loss and better quality of life overall,” explains Davis. “The next phase of evaluation will examine the impact of program participation on healthcare utilization and readmissions among program completers.”

Lay leader Janis Perry has observed that participants are making healthier lifestyle choices, losing weight and increasing their health knowledge through the Living Well program in the communities near MedStar Southern Maryland Hospital Center.

“Participants have stated the positive social aspects of being a part of a group and having accountability to support better management of their conditions,” says Perry. “Having the classes held in the community is essential, as well as having an avenue during the seven weeks to provide evidence-based health information and set goals.”

One of the wraparound components of the program is the recognition of how social needs impact health. In order to sustain self-management behaviors and improved quality of life well after program completion, Living Well program participants are screened for unmet social needs, such as transportation, food access and housing, and are linked to services using the community resource tool Aunt Bertha.​
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To learn more about MedStar Health's programs and initiatives across Maryland and the Washington, D.C., region that are contributing to healthier communities, contact Raquel Lamptey at 410-772-6910