Home / Services / Chronic Disease Management
Chronic Disease Management in Lincoln & Crete, Nebraska
Long-term family medicine care for diabetes, high blood pressure, high cholesterol, thyroid disease, and other chronic conditions. Bilingual English and Spanish care at both ICHI clinics, with the same providers your whole family already knows.
Request an appointmentCall (402) 826-3222
Chronic disease care that stays with you
Chronic conditions like diabetes and high blood pressure aren't fixed in a single visit — they're managed over years. That's the core of what family medicine does. The provider who diagnoses your diabetes is the same one who adjusts your medication next year, coordinates with your endocrinologist, checks your kidney function, screens for complications, and treats the flu or back pain that came up along the way. One record, one team, one plan.
Conditions we manage
Diabetes
Type 1 and type 2 diabetes, prediabetes. Blood sugar monitoring, medication management (metformin, GLP-1s, insulin), diabetes education, and screening for complications (eye, kidney, foot, and heart).
High blood pressure
Hypertension diagnosis, medication management, home blood pressure monitoring guidance, and cardiovascular risk reduction.
High cholesterol
Lipid management with statins and other medications when indicated, lifestyle counseling, and 10-year cardiovascular risk assessment.
Thyroid disease
Hypothyroidism, hyperthyroidism, and thyroid nodule follow-up. Levothyroxine management and monitoring.
Chronic kidney disease
CKD staging, blood pressure and diabetes optimization to slow progression, and coordination with nephrology when appropriate.
Obesity & weight management
Medically supervised weight management, GLP-1 medications when indicated and covered, and coordination of nutrition and lifestyle support.
Asthma & COPD
Inhaler management, exacerbation prevention, and lung function monitoring.
Mental health
Depression, anxiety, and other mood conditions — medication management and referral to counseling as needed.
How chronic care actually works at ICHI
- Regular follow-ups — typically every 3-6 months for stable conditions, more often when things are changing
- Labs on your schedule — HbA1c every 3-6 months for diabetes; lipids, kidney function, and other tests coordinated so you don't do multiple draws
- Medication adjustments — done based on your numbers, side effects, and goals — never rushed, never one-size-fits-all
- Prior authorization support — for GLP-1s, insulins, and other medications that need insurance approval, our team handles the paperwork
- Specialist coordination — referrals to endocrinology, cardiology, nephrology, and others when needed, with results flowing back into your chart
- Complications screening — annual eye exams, foot exams, kidney checks for diabetes; ECGs and heart risk assessments for hypertension
Diabetes care in detail
Diabetes is one of the most common chronic conditions we manage. Our approach covers:
- Diagnosis and staging — HbA1c, fasting glucose, oral glucose tolerance testing when indicated
- Medication — metformin as first line for most type 2, GLP-1 agonists (Ozempic, Mounjaro, Wegovy) when clinically appropriate and covered, SGLT2 inhibitors, insulin when needed
- Blood sugar monitoring — glucometers and continuous glucose monitors (CGM); we help you interpret the data and adjust
- Prevention of complications — annual dilated eye exam referrals, urine microalbumin, foot exams, cardiovascular risk optimization
- Bilingual patient education — English and Spanish diabetes education materials, including our own patient handouts on nutrition and self-care
Blood pressure care in detail
High blood pressure is often silent — you may feel fine while it damages your heart, brain, and kidneys. Our approach:
- Accurate diagnosis, including home blood pressure monitoring to rule out white-coat hypertension
- Individualized medication starting with evidence-based first-line agents (ACE inhibitors, ARBs, thiazides, calcium channel blockers)
- Lifestyle counseling — DASH diet, sodium reduction, physical activity, weight, alcohol
- Regular follow-up to reach and maintain target blood pressure
- Assessment for organ damage — kidney function, urine protein, ECG
Chronic Care Management (CCM) program
For patients with two or more chronic conditions, ICHI is rolling out a formal Medicare Chronic Care Management (CCM) program. Once enrolled, you get dedicated non-face-to-face care coordination between visits — a nurse or care coordinator reviewing your labs, tracking your medications, checking in on symptoms, and making sure specialists and hospitals stay in sync with your primary care team. Enrollment is opening in a phased rollout; if you have Medicare and multiple chronic conditions, ask about CCM at your next visit.
- Available to Medicare and most Medicare Advantage patients with 2+ chronic conditions expected to last at least 12 months
- Requires your consent (verbal or written) before enrollment — and you can cancel at any time
- Small monthly copay may apply, depending on your plan and supplemental coverage
- Complements — not replaces — your regular in-person visits
Bilingual chronic care
Managing a chronic condition is easier when you can talk with your provider in the language you're most comfortable in. Dr. Gutiérrez and Jessica Hernandez Leon, FNP are both bilingual English and Spanish, and our patient education materials are available in both languages. See our página en español.
What to bring to a chronic care visit
- All current medications — bring the bottles if possible
- Recent lab results or specialist notes if seen elsewhere
- Home blood pressure or blood sugar log if you keep one
- Your glucometer or continuous glucose monitor data if you use one
- Insurance card and photo ID
- Questions — chronic care is a partnership
Where we provide chronic care
Frequently asked questions
What chronic conditions do you manage?
Diabetes (type 1 and type 2), high blood pressure, high cholesterol, thyroid disease, chronic kidney disease, obesity and weight management, mental health conditions, chronic pain, arthritis, asthma, COPD, and cardiovascular disease. Any condition that requires ongoing management is typically within scope for family medicine.
How often will I need to be seen?
It depends on the condition and how stable it is. Newly diagnosed or uncontrolled conditions may need visits every 1-3 months. Stable, well-controlled conditions are usually managed with visits every 3-6 months, plus lab checks as needed.
Do you prescribe GLP-1 medications like Ozempic and Mounjaro?
Yes, when clinically appropriate and insurance-covered. We handle the prior authorization paperwork with your insurance and select the medication that fits your diagnosis (diabetes vs. weight management) and coverage.
Do you coordinate with my specialists?
Yes. We coordinate with endocrinology, cardiology, nephrology, and other specialists when needed. As your primary care team, we track the whole picture and make sure specialist recommendations fit with the rest of your care.
Do you offer a Chronic Care Management (CCM) program?
Yes. ICHI is rolling out a formal Medicare CCM program for patients with two or more chronic conditions. Enrollment is opening in phases — ask at your next visit if you're interested. CCM adds dedicated between-visit care coordination on top of your regular office visits.
Do you offer diabetes education?
Yes. We provide in-office diabetes education covering blood sugar monitoring, medication use, diet, exercise, and preventing complications. Bilingual education materials in English and Spanish are available.
Do you accept Medicare and Medicaid for chronic care?
Yes. We accept Medicare, Medicare Advantage plans, Nebraska Medicaid Heritage Health (Nebraska Total Care, Molina, UnitedHealthcare Community Plan), and most commercial plans.