Chronic Care Management Nurse Team: Helping Patients Stay Healthy Between Visits 

The diagnosis of a chronic condition like diabetes, heart disease, or high blood pressure can change a patient’s life in an instant. For the one in four adults in the U.S. living with

Mattie Bazan, a member of the Chronic Care Management Nurse Team, talks with a patient by phone.

multiple chronic conditions, keeping up with medications, appointments, symptoms, and lifestyle changes often requires more support than a visit or two with a healthcare provider each year. Yakima Valley Farm Workers Clinic's (YVFWC) Chronic Care Management Nurse Team helps patients navigate those challenges with ongoing support, education, and guidance. 

The program supports patients living with diabetes, high blood pressure, heart disease, chronic kidney disease, arthritis, chronic bronchitis, asthma, high cholesterol, depression, anxiety, and other chronic conditions. Each patient receives a comprehensive assessment and a personalized care plan tailored to their needs and priorities. 

“We meet the patient where they are,” said Melissa Zimmer, Supervisor of the Chronic Care Management Nurse Team. “They could be anywhere from newly diagnosed to living with the condition for a long time. We focus on what their priorities are.” 

The team’s four nurses provide personalized guidance to 680 YVFWC patients living with two or more chronic conditions. They conduct monthly telephone visits and occasional in-clinic appointments to answer patient questions, coordinate care, and help them address health concerns before they become emergencies. 

"We primarily help patients understand their chronic conditions," said Zimmer. "We provide education, talk with them about their health goals, and offer support and information." 

That support can make a meaningful difference in patients’ lives. YVFWC patients with diabetes who enter the program with A1C levels of 12 or higher often lower those levels to around 7 within months of working with the Nurse Team. The Chronic Care Management Nurse Team has also helped reduce unnecessary emergency department visits by teaching patients to recognize warning signs early and connect with their healthcare team sooner. 

“Our patients gain confidence in managing their health,” said Zimmer. “That equates to positive health outcomes for those patients and adds to their quality of life.”