Primary Care

Chronic Disease Management

In 2005, 60% of all deaths were due to chronic diseases. CCFHS providers are focused on preventing chronic diseases through prevention screening continuity of care and patient education. Many chronic diseases are preventable through adopting a healthy eating and active lifestyle. In addition by following recommended immunization and follow-up appointments, patients can improve the management of COPD, heart disease, hypertension, lung diseases, diabetes and manage other diseases.

Approximately 23% of our population is obese, 28% have high blood pressure, and over 7% are currently dealing with diabetes. Over 28% of our population report getting no regular exercise, but because most in the region count ATV and snowmobile operation as exercise, we suspect that this is underreported! Over 73% of adults report having limited access to daily fruits and vegetables for their consumption. Although there are farmers who offer fresh fruits and vegetables within the region, they often are not accessible within the City of Berlin. At CCFHS clinics over 17% of the clients do not have regular transportation so getting to remote farm stands is difficult. There is no farm to school program nor a sanctioned farmers market in the Berlin/Gorham area.

For the past year, a subset of the Androscoggin Valley Concerned Community Providers (AVCCP) has been working toward a collaborative program to promote Healthy Living and Active Lifestyles. CCFHS has been writing grant proposals and facilitating the planning process. Both CCFHS and AVH are committed to reducing the number of people diagnosed with diabetes, particularly the number of children that develop type-2 diabetes. They are also interested in their patients adopting a more active lifestyle.

Both the school system and medical providers measure Body Mass Index and have the ability to contract with students and patients to take action. Locally, the team measures in both children and adults:

• Overweight/obesity prevalence
• The increase in the percentage getting adequate physical activity
• The decrease in reported consumption of sugar-sweetened beverages
• The increase in average daily fruit and vegetable consumption
• The increase in the percentage with a heart-healthy diet based on USDA’s Healthy Eating Index, meaning a diet including adequate (at least five servings) fruits and vegetables and reduced intake of fats.
• A decrease in the percentage getting excess calories based on USDA’s Healthy Eating Index.