Home-based Diabetes and Heart Failure Program

Core Health is a continuum-based program offering 12 months of home-based services for adults with heart failure or diabetes. Patients must be able to participate in a self-management program.

The Care Team

A registered nurse case manager plans and prioritizes care in collaboration with a community health worker. The community health worker supports and mentors clients working toward healthy habits by helping to identify and address barriers.


Through weekly, biweekly or monthly visits, Core Health will:

  • Assist in reducing 30-day readmissions
  • Improve compliance with HEDIS measures
  • Support health care appointment adherence
  • Assist with medication adherence
  • Monitor blood pressure
  • Measure BMI
  • Check feet for diabetes patients
  • Monitor heart failure zones
  • Provide education on health condition
  • Motivate toward self management
  • Set and monitor personal goals for behavior modification
  • Connect clients to community resources
  • Provide ongoing communication with primary care provider

Contact Us

In Kent County area:

Core Health Program
75 Sheldon Boulevard, Suite 202
Grand Rapids, Michigan 49503
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Phone: 616.391.6135
Fax: 616.391.6165

In Spectrum Health United Hospital and Kelsey Hospital areas:

Core Health Program
407 S. Nelson
Greenville, MI 48838
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Phone: 616.754.6185 or 800.406.4551
Fax: 616.754.6407