A community-based case management model for hypertension and diabetes

Health research conducted over the past 15 years in the Mississippi Delta has continually documented a population experiencing poor health status (high rates of chronic diseases and excessive related mortalities). Both individual and health system resources are scarce in this region, posing barriers to effective chronic disease management. Two of the most significant chronic diseases that burden this population are hypertension and diabetes. To address this issue, the Delta Community Partners In Care project centering on chronic disease control was developed by a consortium of local health care institutions and supported by a national foundation. The intervention model centers on the utilization of a community-based case management approach in 13 clinical sites. Both compliance to pharmacological and individualized nonpharmacological therapy and continuity of care are stressed. A number of outcome measures showed significant improvement over the 24 month project period (N = 756).