Role of Public Health:

  • Help to increase awareness of chronic disease and management
  • Be a convener to help bring partners together (healthcare teams / Pharmacy / Quality Improvement orgs, health information technology, payers)
  • Share Information (national and state initiatives / programs)
  • Promote the implementation of healthcare policies to support quality, value, and improved population health outcomes, and to reduce health disparities
  • Promote health prevention and chronic disease self-management by supporting a multi-disciplinary team approach
  • Can provide technical assistance to programs in reviewing quarterly data by utilizing staff evaluators and epidemiologists to assist with data interpretation
  • Provide scientific expertise on evidence-based interventions
  • Provides clout and importance to interventions


Role of the Pharmacist:

  • Fills prescriptions per providers orders, after checking for any contraindications
  • Educate patients on how and when to take medicine, advising on potential side effects
  • Advises about general health topics
  • Teaches other healthcare practitioners about proper medication therapies for patients
  • Completes insurance forms
  • Oversees the work of pharmacy technicians and pharmacists in training (interns)

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How to Partner with the Pharmacist:

  • Learn what pharmacists can and cannot do in your state by checking with the Board of Pharmacy
  • Meet with local pharmacists to discuss their role in hypertension control and management such as; performing in-pharmacy blood pressure (BP) checks, advising on home BP self-monitoring, educating patients on hypertension medications, and tracking refill patterns
  • Meet with local pharmacists to discuss their role in diabetes control and management such as; in-pharmacy blood glucose checks, advising on home blood glucose monitoring, educating patients on diabetes medications, and tracking refill patterns
  • Discuss possible models for hypertension and/or diabetes management with engaged pharmacists providing resources and/or examples (i.e. team-based care models)


Case Manager/Nurse:
Case Managers are frequently Registered Nurses (RNs) who:

  • Develop, implement, and evaluate individualized care plans for patients
  • Advocate for the safety of patients
  • Act as a liaison between healthcare providers, families of patients and the patients themselves
  • Educate their patients and their families on how to follow their care plans

How to Partner with the Case Manager/Nurse:

  • Share tools and resources on how to identify and track patients with a diagnosis of diabetes and/or hypertension
  • Educate Case Managers on available community resources to assist the patient in chronic disease management
  • Share information regarding state and national programs
  • Convene like healthcare providers to share resources and effective patient management techniques


Role of the Community Health Worker (CHW):

  • Typically, lay person from the community
  • Provides general health education
  • Serve as role models and community advocates
  • Increase access to healthcare resources
  • Collect data for research/quality improvement purposes

For more information, see Community Health Worker in the
Health Care Models button on the home page

How to Partner with the Community Health Worker (CHW):

  • Advocate and promote the implementation of CHW role descriptions and policies within healthcare systems/provider practices
  • Share information regarding available community resources to assist patients with chronic disease
  • Promote health prevention and chronic disease self-management by supporting a multi-disciplinary team approach



Entities other than the patient that finance or reimburse the cost of health services. In most cases, this term refers to insurance carriers, other third-party payers, or health plan sponsors (employers or unions).

How to Partner with the Insurer/Employer:

  • Assist and advocate for Insurers to rework new models of care to pay for diabetes and high blood pressure medications and supplies to include home monitoring
  • Assist Insurers who collect and share data for quality improvement
  • Partner to improve public awareness through education


A generalist physician and/or non-physician practitioners (nurse practitioners and physician assistants)

Role of the Primary Care Provider:

  • Serves as the entry point for the patient's health care needs
  • Takes continuing responsibility for providing the patient's care
  • Serves as an advocate for the patient, coordinating the entire health care system to benefit the patient

How to Partner with the Primary Care Provider:

  • Identify which providers in your state are reporting to a national quality program such as NCQA (see Basic Component Button on home page)
  • Share available community resources to assist their patients (i.e. blood pressure screenings/smoking cessation/ etc...)
  • Discuss current patient tracking for patients with hypertension and/or diabetes
  • Share resources with PCP and office to assist with blood pressure and diabetes management (i.e. algorithms)
  • Convene healthcare team to explore how all can work to their highest level

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Role of the Behavioral Health Specialist:

  • Assist primary health care providers in recognizing and treating mental disorders and psychosocial problems
  • Assist in preventing relapse or morbidity in conditions that tend to recur over time
  • Evaluate patient care plans with primary care team
  • Teach patients, families and staff about care, prevention and treatment enhancement techniques

How to Partner with the Behavioral Health Specialist:

  • Convene healthcare teams including PCP/staff and Behavioral Health Specialist to promote improved communication resulting in team-based, patient-centered care
  • Advocate for improved awareness and coverage of mental health /behavioral disorders
  • Share resources for patient tracking (i.e. hypertension and/or diabetes)
  • Share information regarding community resources for patients with mental health/behavioral disorders