Enhanced Care Disease Management ProgramsThe UNC Internal Medicine Enhanced Care Programs were established in 1999 with the goal of providing high quality proactive care to vulnerable patients who suffer from chronic illness such as diabetes, chronic pain, and disorders that require chronic anticoagulation. Each program tailors interventions to meet the needs of the Divisions patient population. To meet these needs clinical services are provided in clinic and via telephone. Clinic services are provided in individual, group, and class settings. Care is directed by a computerized registry and treatment algorithms and led by expert staff in the assessment, medical management, and self-care education of these chronic illnesses. The Enhanced Care Programs rigorously evaluate care provided on a monthly basis in multidisciplinary meetings. These programs are evaluated and findings are disseminated through peer reviewed publications. Traineeships and postgraduate pharmacy residency opportunities are available. Here are some important links for Enhanced Care:
Click here for commonly used forms. Diabetes ProgramThe Center for Excellence in Chronic Illness Care and UNC Internal Medicine has developed, tested, and disseminated a program of disease management for vulnerable patients with diabetes. This is now known as the Enhanced Care Program, Diabetes Care Program. The program utilizes a customized patient registry, evidence-based treatment algorithms, and a multidisciplinary team approach to care anchored by physician extenders that include a clinical pharmacist practitioner, nurse practitioner, registered dietician, and care assistants. The Diabetes Program focuses on improving blood glucose and cardiovascular risk, including better control of hypertension, lipid treatment, smoking cessation, and use of aspirin and statins to prevent cardiac events. We also focus on disease prevention by encouraging vaccination, foot care, and ophthalmologic evaluation. In addition, the Program focuses on improving patient’s diabetes-related knowledge and self-care, while also improving satisfaction with care. We also believe that lasting improvements in clinical outcomes may not be attainable without addressing social disparity and treating and screening for depression. Interestingly, improvements appear greatest for the most vulnerable patients, including those with low educational attainment and poor reading skills. The program provides services from within the ACC-based UNC Internal Medicine Clinic. Encounters occur in clinic either in a one-on-one basis or in a group setting. We also provide telephone follow-up and by provide feedback to UNC providers regarding their quality of care.
Click here for commonly used forms ADA-Approved Diabetes Self Management ClassThe UNC Diabetes Enhanced Care Program has been recognized by the American Diabetes Association for Quality Self-Management Education*. The goal of our program is to provide our patients with the tools to manage their diabetes and improve health outcomes by delivering diabetes self-management o education* to the people of North Carolina. The class is set up as a one-time workshop which lasts approximately 4 hours. Currently, we offer the class twice a month on Tuesdays. Options include a morning class from 8AM-11:00AM and an afternoon class from 12:30-4:30PM. The curriculum content follows the American Diabetes Association guidelines for diabetes self management education*. Personalized goals are set at the end of class and reevaluated at follow up visits.
Anticoagulation ProgramThe Internal Medicine Anticoagulation Clinic within the Enhanced Care Program currently manages over 350 patients. This clinic focuses on the management of “blood thinners”, especially coumadin/warfarin, in patients with a variety of indications including blood clotting disorders, deep vein thrombosis, pulmonary embolism, patients with heart valves and those with atrial fibrillation. This clinic utilizes evidenced-based treatment and a multidisciplinary team consisting of two clinical pharmacist practitioners, a physician assistant, nurse practitioner, and a registered nurse. These clinicians manage warfarin and other anticoagulants, adjusting doses when appropriate, as well as handle anticoagulant management during invasive procedures.
Click here for commonly used forms Pain Management ProgramThe Center for Excellence in Chronic Illness Care has developed, tested, and disseminated a program of disease management for vulnerable patients with nonmalignant chronic pain. The program utilizes a customized patient registry, evidence-based treatment algorithms, and use of a multidisciplinary team approach to care anchored by physician extenders that include a clinical pharmacist practitioner, a nurse clinician, and a care assistant. The General Medicine Pain Service (GMPS) manages over 200 patients with nonmalignant chronic pain. These patients require direct referral to the GMPS by providers in the UNC Internal Medicine Clinic. Goals of the program include reducing a patient’s day-to-day pain, improving a patient’s ability to participate in activities of daily living, and addressing overlaying symptoms such as sleep and/or mood disorders. The GMPS works to achieve these goals through pharmacological management as well as outside referral for non-medication based rehabilitation such as physical or aquatic therapy, surgical or procedural intervention, and cognitive-behavioral therapy. The GMPS also focuses on disease prevention by encouraging self-care through exercise, improvement in diet, smoking cessation, and enrollment in other disease management programs, including diabetes management and/or anticoagulation care.
Click here for commonly used forms Traineeships and Residency ProgramThe University of North Carolina at Chapel Hill Division of General Medicine and Clinical Epidemiology provides primary and consultative clinical care to both the inpatient and outpatient population at UNC Hospitals and affiliated practices. The focus of our services is not only on the relief of symptoms, but also on the prevention of illness and promotion of health. Multidisciplinary programs, known as our Enhanced Care Programs, focus on the management of diabetes, heart failure, anticoagulation and chronic pain and are available to patients in the practice.
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University of North Carolina at Chapel Hill
Division of General Medicine & Clinical Epidemiology
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