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Chronic Care Management


Greene County Medical Center
1000 West Lincoln Way
Jefferson, Iowa 50129
(515) 386-0526

Chronic Care Management

Giving the patient what they need at the time they need it.

Chronic Care Management is a comprehensive program that focuses on the individual as a whole to promote overall health. Chronic Care Management works with individuals to ensure they are knowledgeable about their chronic conditions as well as ensures they have access to needed resources and services. Chronic Care Management is a service available to individuals with two or more chronic conditions and will provide patients with 24/7 access to care that helps you stay on track with treatments and your overall health goals.


  • Helping you connect with community resources and support groups
  • Personalized goal-setting and care plan
  • Facilitating communication and coordinating with other care teams
  • Help manage medications and overcoming barriers 
  • Disease self-management education and support
  • Medication reconciliation 
  • Referrals to community services as needed

Chronic Care Conditions include, but are not limited to:

  • COPD
  • Diabetes
  • Hypertension 
  • Heart Failure
  • Depressions 
  • Asthma

How to Enroll

Talk with your provider at your next appointment in the Greene County Family Medicine Clinic, to see if you qualify for Chronic Care Management or call 515-386-0526.