Chronic disease management

Chronic disease management is a coordinated, long-term care approach designed to help people with ongoing conditions such as diabetes, heart disease, chronic obstructive pulmonary disease (COPD), hypertension, arthritis, and chronic kidney disease maintain optimal health and quality of life. Instead of focusing on a single treatment, this service combines personalized medical care, lifestyle support, education, and regular monitoring. The goal is to prevent complications, reduce symptoms, and support daily routines in a way that works for you.

What this service includes

• Comprehensive assessment and individualized care plan: We review your medical history, medications, symptoms, lifestyle, and goals to create a care plan tailored to your needs.
• Medication management: Our team regularly reviews prescriptions, supports adherence, adjusts doses as needed, and coordinates with specialists and pharmacies to minimize side effects and interactions.
• Routine monitoring and follow-up: Clinic visits, remote check-ins, and tests such as lab work, blood pressure or glucose logs, and spirometry track progress and detect changes early.
• Self-management education: Training on symptom recognition, medication use, healthy eating, physical activity, stress management, and daily care skills.
• Care coordination: TidalHealth brings together your primary care provider, specialists, nurses, pharmacists, and allied health professionals—such as dietitians, physical therapists, and behavioral health counselors—to ensure unified care.
• Access to supportive services: Connections to resources like smoking cessation programs, weight-management counseling, rehabilitation, and mental health support.

What to expect when you enroll

• Initial visit: Review of your health, treatments, and goals, which may include a physical exam, lab tests, and medication review.
• Written care plan: Clear short- and long-term goals, easy-to-follow medication and self-care steps, and a schedule for follow-up visits.
• Regular touchpoints: In-person, phone, or telehealth check-ins, depending on your needs and preferences.
• Plan adjustments: Your care plan is updated over time based on your symptoms, test results, and priorities.

Our goals and how we support you
TidalHealth aims to reduce symptoms, prevent or delay complications, avoid unnecessary hospital stays, and help you manage daily activities independently. Success looks different for each person — whether better blood sugar control, fewer breathing episodes, improved mobility, or greater confidence in your care. Our team works closely with you and your family to measure progress and adjust your plan so you feel supported every step of the way.

Who should consider chronic disease management services?
Anyone with a long-term health condition — such as diabetes, heart disease, COPD, hypertension, arthritis, or chronic kidney disease — that requires ongoing monitoring, medication, or lifestyle changes can benefit. People with multiple conditions or frequent hospital visits often find coordinated management especially helpful.

How do I enroll or get referred?
Enroll by contacting TidalHealth directly, speaking with your primary care provider, or being referred by a specialist. Many practices also accept self-referrals. Our team provides next steps when you reach out.

What happens at the first visit?
A thorough review of your medical history, medications, symptoms, and daily routines. Relevant exams and tests are completed, goals are set, and a personalized care plan is created.

Will I still see my specialist or primary care doctor?
Yes. Chronic disease management complements care from your usual doctors. Our team coordinates with them to ensure consistent, connected care.

How often will I have follow-up visits?
Follow-up frequency depends on your health and stability. This may range from weekly or monthly check-ins when starting or adjusting treatment to quarterly or biannual visits for stable conditions. Remote monitoring and phone check-ins can reduce the need for frequent in-person visits.

Do you offer telehealth or remote monitoring?
Yes. Many programs include telehealth visits, phone check-ins, and remote monitoring tools such as home blood pressure monitors, glucose meters, or weight scales.

Will my medications be changed?
Medication adjustments are common and based on symptoms, test results, side effects, and treatment goals. Changes are discussed with you before implementation.

How do you help with lifestyle changes like diet and exercise?
We provide practical education, goal-setting, and referrals to dietitians, exercise programs, or rehabilitation services, focusing on manageable steps and ongoing support for lasting habits.

What if I cannot afford medications or tests?
TidalHealth can discuss cost concerns, identify affordable options, connect you with medication assistance programs, and link you to community resources to reduce financial barriers.

When should I seek urgent care or call 911?
Call 911 or seek emergency care for severe chest pain, sudden shortness of breath, sudden weakness or slurred speech, uncontrolled bleeding, fainting, or other life-threatening symptoms. For worsening but non-life-threatening symptoms, contact your care team promptly.