Chronic Disease Management

Call for more information at 814-8749 or 898-1700.



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The need for improved management of patients with chronic diseases in St. Louis is great. According to the St. Louis City Department of Health’s document, City of St. Louis, Understanding Our Needs, June 2007, these studies performed from 2002 to 2005 indicated that, in St. Louis, African-Americans are 4.4 times more likely to be hospitalized than Caucasions. Also among African-Americans, St. Louis has one of the highest average death rates in the country due to diabetes, heart disease, cancer, and stroke.

Grace Hill Health Centers, Inc. (GHHC) initiated the Chronic Disease Management (CDM) program in 1998 with a diabetes collaborative sponsored by the Bureau of Primary Health Care and the Institute for Health Care Improvement. Chronic diseases are debilitating, and the most commonly occurring are cardiovascular disease, asthma, cancer, and diabetes.

Since GHHC instituted the CDM program, staff have participated in other bureau-sponsored collaboratives: cancer screening and treatment; attention deficit hyperactivity disorder (ADHD); and asthma. To help combat these diseases, the CDM department provides in-home coaching and support to patients suffering from chronic diseases. Health care coaches educate patients on the importance of ownership of their medical care management. Also, in conjunction with the clients’ physicians, the coaches provide clients with self-management options to improve their quality of life. Cluster clinics and support groups have been established to provide peer support.

In 2006, Grace Hill received a grant to develop the “With Every Heart beat is Life” (WEHL) program. The 12-week cardiovascular program is for African Americans residing in public housing. Health coaches teach the program, using a program manual created for African-American communities by the National Heart, Lung and Blood Institute at the National Institute of Health. In 2007, health coaches visited ten public housing apartment complexes teaching 107 participants how to set their individual self-management goals.

Also in 2007, Grace Hill received funding to begin using the Missouri Screen for Life – Colorectal Cancer Screening Demonstration Program.

Grace Hill was also funded in 2007 by the Missouri Foundation for Health for a three-year “Better Self Management of Diabetes” (BSMOD) program. The program is unique because it trains Health Coaches to support diabetic patients who want to reach their self-management goals. It also creates opportunities for patients to participate in holistic self-care skills classes. This program helps patients build a strong foundation of self-management and self-help.

Many new partners are collaborating with Grace Hill to reach more members of the community. Grace Hill has also benefited from renewed grants, such as the AVON Foundation’s grant for Breast Cancer Awareness. In addition, Grace Hill’s mobile mammography and breast cancer screening program, in partnership with Barnes-Jewish Hospital, conducted 865 mammograms, exceeding its goal for 2007.


For more information, call 814-8749 or 898-1700.