Chronic Disease Management Program
Move from occasional treatment to continuous, coordinated care through regular monitoring, doctor review, laboratory testing, medication support, lifestyle guidance, and early intervention.
Long-term care built around the patient
Merita Health's Chronic Disease Management Program is designed to support patients who need regular medical monitoring, coordinated follow-up, laboratory testing, medication support and early action when their condition changes.
Conditions Covered
- Hypertension
- Diabetes mellitus
- Heart disease
- Chronic kidney disease
- Asthma & COPD
- High cholesterol
Additional Conditions
- Obesity / metabolic syndrome
- Thyroid disorders
- Chronic liver disease
- Gout
- Multiple chronic conditions / comorbidities
- Elderly patients requiring regular monitoring
Manage today. Live better tomorrow.
One care plan connecting doctors, nurses, laboratory, pharmacy, specialists and home care.
Basic, Standard and Premium care options
Program fees are customized to each patient. Exact tests and monitoring frequency should be individualized by the treating clinician.
| Service | Basic | Standard | Premium |
|---|---|---|---|
| Doctor consultation | Monthly | Monthly | Monthly |
| Nurse follow-up | 1/month | 2/month | Weekly |
| Vital signs monitoring | ✓ | ✓ | ✓ |
| Blood pressure monitoring | ✓ | ✓ | ✓ |
| Blood sugar monitoring | ✓ | ✓ | ✓ |
| Medication review | Quarterly | Monthly | Monthly |
| Laboratory monitoring | Every 6 months | Every 3 months | Monthly / according to condition |
| Diet & lifestyle counselling | ✓ | ✓ | ✓ |
| Telemedicine follow-up | — | ✓ | ✓ |
| Home visit | — | Optional | 1/month |
| Specialist coordination | — | ✓ | ✓ |
| Pharmacy medication support | ✓ | ✓ | ✓ |
| Emergency / early-warning follow-up | — | ✓ | ✓ |
| Family / caregiver updates | — | Optional | ✓ |
| Program fee | Custom | Custom | Custom |
Exact tests and frequency should be individualized by the treating clinician.
Focused monitoring for common chronic conditions
Each pathway combines baseline assessment, scheduled review, medication support and referral where clinically indicated.
Diabetes Management Package
- Doctor consultation and full medical history
- Blood pressure, weight/BMI and blood glucose
- HbA1c, kidney function, lipid profile and urine testing
- Medication and complication-risk review
Monthly: Doctor/nurse follow-up, blood sugar review, medication adherence, diet and lifestyle review.
Every 3 months: HbA1c, doctor review and treatment adjustment where indicated.
Annually / clinically indicated: Kidney, eye, foot and cardiovascular risk assessment.
Hypertension Management Package
- Blood pressure and cardiovascular risk assessment
- Kidney function, electrolytes and lipid profile
- Blood glucose / HbA1c where appropriate
- Medication review
- Home BP monitoring and monthly review
- Medication adherence checks
- Lifestyle, salt-intake and weight counselling
- Periodic laboratory testing and referral when indicated
Heart & Cardiovascular Package
For patients with hypertension, heart disease, previous cardiac events, heart failure or high cardiovascular risk.
- Cardiovascular assessment, BP and weight monitoring
- Medication reconciliation and ECG when indicated
- Lipid monitoring and diabetes screening
- Lifestyle counselling and cardiology referral
- Post-hospital follow-up and warning-sign education
- Coordination of investigations and specialist care
Kidney Disease Package
Monitoring may include:
- Blood pressure, creatinine/eGFR and electrolytes
- Urinalysis and urine albumin/protein assessment
- Diabetes monitoring and medication review
- Dietary counselling and nephrology referral
For advanced kidney disease, the program can integrate dialysis, nephrology and transplant-care coordination.
From enrollment to continuous review
A simple pathway keeps every chronic-care patient connected to the right monitoring and clinical support.
Enroll
Patient registers for the chronic-care program.
Baseline Assessment
Doctor + nurse + laboratory assessment.
Personal Care Plan
A personalized treatment and monitoring plan is created.
Continuous Monitoring
BP, glucose, weight, symptoms, medicines and laboratory results.
Monthly Review
Doctor/nurse reviews progress.
Early Intervention
Abnormal results or deterioration trigger review or referral.
Quarterly Review
Progress, treatment response and risk factors are reassessed.
Additional support when patients need more care
Home Care
- Home doctor consultation
- Nurse visit
- Blood sample collection
- BP/glucose monitoring
- Medication support
Pharmacy Support
- Prescription coordination
- Medication refill reminders
- Medication delivery where available
- Adherence monitoring
Laboratory
- Scheduled chronic-disease panels
- Home sample collection
- Results tracking
Specialist Care
- Cardiology
- Nephrology
- Internal medicine
- Endocrinology
- Geriatrics
- Other specialist referrals
One care record for ongoing monitoring
Every enrolled patient should have a Merita Chronic Care Record that keeps key clinical and follow-up information in one place.
Patient
- Name
- Diagnosis
- Emergency contact
- Primary physician
Clinical Targets
- BP target
- HbA1c target where applicable
- Weight target
- Other individualized targets
Medication
- Drug
- Dose
- Frequency
- Start date
- Review date
Monitoring
- BP
- Pulse
- Weight
- Glucose
- Laboratory results
Appointments & Follow-up
- Last consultation
- Next consultation
- Specialist appointments
- Laboratory due dates
Monthly care instead of fragmented routine visits
The program can be structured as a monthly membership rather than charging separately for every routine interaction.
Basic Care
For stable patients who mainly need monitoring.
- 1 doctor review/month
- Routine nurse follow-up
- Vital-sign monitoring
- Medication review
- Selected laboratory monitoring
- Patient education
Standard Care
For patients requiring closer monitoring. Includes everything in Basic, plus:
- More frequent nurse contact
- Telemedicine
- Quarterly laboratory package
- Specialist coordination
- Medication/refill support
Premium Care
For elderly, complex or multi-morbidity patients. Includes everything in Standard, plus:
- Priority appointments
- Regular home-care support
- More frequent monitoring
- Family/caregiver coordination
- Comprehensive quarterly review
- Specialist-care coordination
One team. One care plan. Continuous monitoring.
The program is not simply about discounted consultations. It is a coordinated system connecting the patient's complete care journey.
This is particularly valuable for patients taking several medications or seeing multiple doctors.
DON’T WAIT UNTIL YOU FEEL SICK.
Take Control of Your Chronic Health.
Merita Health Chronic Disease Management Program — Regular Monitoring | Doctor Reviews | Laboratory Testing | Medication Support | Lifestyle Care | Home Care
Enroll today and let Merita Health help you manage your health for the long term.