Chronic Disease

Prevention & Control

Connecting community members with the information, tools, resources, and services to better address their needs.


This project aims to integrate health system and community approaches to improve chronic disease management and control.

Addressing Disparity

This project works to better provide for Medicaid beneficiaries (adults and children) with, or at risk for, arthritis, cancer, chronic respiratory disease (asthma), diabetes, heart disease, obesity and stroke, with a focus on those populations experiencing the greatest burden of chronic disease(s) in the region.


OCH aims to guide practice transformation around the management of diabetes, cardiovascular disease, hypertension, and asthma. Primary Care and Behavioral Health Change Plans are designed to align with existing state efforts. Existing efforts include offerings of Chronic Disease Self-Management (CDSM), including Wisdom Warriors, and Diabetes Prevention Programs (DPP), primarily through community-based organizations and Tribal clinics. 

Partner Success:

Olympic Area Agency on Aging partnered with primary care to offer chronic disease self-management programs on-site at NOHN, OMC, and Jamestown.