1. Health Care
1.1. Who is healthcare for?
1.1.1. Patients with Chronic diseases
1.1.1.1. At more risk for more health complications
1.1.1.2. Need more assistance from healthcare providers
1.1.1.3. May need other ways to pay for healthcare
1.1.2. The general public
1.1.2.1. Population
1.1.2.1.1. Strategies for the population
1.1.2.1.2. Population with modify risk
2. Outreach
2.1. Critical Services
2.1.1. Follow up services
2.1.2. disease registries facilitates
2.1.3. Health Care Providers
2.2. Types of Care
2.2.1. Lower level care
2.2.1.1. Transferring from inpatient care to home care.
2.2.1.1.1. Effective Transitional Care
2.2.2. Clinical Care
2.2.2.1. medication reconciliation
2.2.2.2. self management support
2.2.2.3. assessment of adherence to treatment plans
2.2.3. Transitional Care
3. Self Management
3.1. Caring for patients with chronic diseases
3.1.1. How are patients dealing with diseases
3.1.2. What can we do to them understand their disease better?
3.1.3. Do patients have the tools and resources needed
3.2. Understanding the patient to help them out
3.2.1. Do we know the patient's backstory?
3.2.2. Is the patient comfortable in this environment?
3.3. Care Mangers
3.3.1. Motivational Interviewing
3.3.1.1. Setting goals
3.3.1.2. Tracking Progress
3.3.1.3. Readiness to change