Chronic Disease Management: How EMC Ohio Uses the Chronic Care Model to Improve Outcomes
At EMC Ohio, we believe healthcare should feel personal, proactive, and genuinely centered around you. For the millions of Americans living with chronic conditions, good care isn't just about treating symptoms when they pop up. It's about building a lasting plan that helps you live better every day.
That's what chronic disease management is really about. We want to walk you through what makes our approach different, including the Chronic Care Model we use, why having a structured care plan matters, and how working with a dedicated team (instead of being passed around) leads to better outcomes.
The Chronic Care Model is a framework that transforms how healthcare teams support patients with long-term conditions like diabetes, hypertension, heart disease, and COPD.
Instead of waiting for symptoms to flare up, this model focuses on continuous, coordinated care. It empowers you to take control of your health while keeping your providers closely connected to your progress.
The model rests on six key pillars:
Health System Organization – Building a foundation that supports proactive care instead of reactive treatment
Self-Management Support – Teaching and motivating you to take ownership of your health
Delivery System Design – Using team-based care with planned visits and consistent follow-ups
Decision Support – Relying on evidence-based guidelines and clinical tools to guide your care
Clinical Information Systems – Tracking your results, spotting trends, and identifying gaps before they become problems
Community Resources and Policies – Connecting you with programs and support that extend beyond the clinic
When these pieces work together, you get a care system that's organized, data-driven, and truly focused on you as a person. That's exactly what we aim for at EMC Ohio.
Why a Structured Care Plan Matters
Think of your chronic care management plan as your personalized roadmap. It organizes your medical information, health goals, and action steps into one clear structure that your care team can follow alongside you.
A strong care plan helps us:
Track key health metrics like blood pressure, glucose, and cholesterol
Set and monitor goals that matter to you
Schedule follow-ups and check-ins at the right times
Clarify each team member's role in your care
Document lifestyle changes, medication adjustments, and lab results
Spot trends or potential concerns early
At EMC Ohio, we tailor each plan to fit your life and goals. No two patients are alike, so our plans aren't cookie-cutter templates. They're customized, collaborative, and designed to evolve as your needs change.
How EMC Ohio Is Different from Traditional Chronic Care Management Services
Some healthcare providers work with third-party chronic care management companies that offer remote monitoring, patient education, or administrative support like scheduling and reporting. These services can be helpful, especially for larger health systems, but they often create distance between you and your primary care team.
At EMC Ohio, we take a different approach. Because we're a concierge primary care practice, we handle all aspects of your chronic care directly within our team. That means:
You always work with the same trusted providers who know your story
Communication stays personal and seamless
Your care plan is owned by one team, not outsourced to multiple companies
You get the same level of follow-up and accountability every step of the way
We combine the structure and technology of larger chronic care programs with the warmth, familiarity, and accessibility you'd expect from a small, dedicated practice.
What Makes EMC Ohio's Approach Stand Out
We believe the best outcomes come from care that's personal, proactive, and deeply connected. Here's how we make that happen:
Smaller Patient Panels – Our physicians care for a limited number of patients, which means more time and attention for you.
Ongoing Communication – We don't just wait for your next appointment. We check in, follow up, and adjust your plan as needed.
Integrated Data Tracking – Our systems monitor key metrics and alert us to changes before they become serious problems.
Specialist Coordination – We serve as your care hub, making sure no details fall through the cracks when you see other providers.
Empowerment and Education – We teach, support, and guide you because you're an active partner in your own care.
The result is truly continuous care. Not just better numbers on a chart, but a better quality of life.
Key Takeaways
The Chronic Care Model provides a proven structure for effective, proactive chronic disease management
A structured care plan helps your healthcare team stay organized, informed, and aligned with your goals
While some practices outsource chronic care management, EMC Ohio delivers those same benefits within a concierge, patient-centered setting
Our team combines data-driven care with the human connection that makes real healing possible
Frequently Asked Questions
What is the Chronic Care Model in healthcare?
The Chronic Care Model is a framework that guides how providers deliver care to people with long-term health conditions. It emphasizes coordinated, proactive management rather than reactive treatment, which improves patient outcomes and reduces hospital visits.
What should be included in a chronic care management plan?
A strong plan should include your health goals, current medications, vital statistics, lab results, scheduled follow-ups, and the roles of your care team members. It serves as a living document that grows and changes with you.
What do chronic care management companies do?
These companies offer support services like remote monitoring, care coordination, and data tracking for healthcare providers. They help practices manage large patient populations, though concierge practices like EMC Ohio typically handle this internally for a more personal experience.
How does EMC Ohio manage chronic diseases differently?
At EMC Ohio, your physician isn't rushing between hundreds of patients. With smaller patient panels, we have time to review your data, communicate proactively, and truly personalize your plan. You'll always know your care team, and they'll always know you.
Who benefits from chronic care management?
Anyone with ongoing conditions like diabetes, heart disease, COPD, high blood pressure, or high cholesterol can benefit from structured chronic care management. It's especially valuable if you want continuous support, early intervention, and consistent guidance rather than waiting until something goes wrong.
Partner with EMC Ohio for Personalized Chronic Care
If you or a loved one is managing a chronic condition, it's time to experience care that's proactive, connected, and designed around you.
At EMC Ohio, we bring the Chronic Care Model to life one patient, one plan, one partnership at a time.
Ready to take control of your health? Contact us today.