Empowering Patients Through Coordinated, Continuous Care
Understanding Management of Chronic Care
- Possess two or more chronic conditions expected to persist for at least 12 months or until the end of life
- Are at a significant risk of death, acute exacerbation/decompensation, or functional decline
- Diabetes
- Hypertension
- Heart Disease
- Chronic Obstructive Pulmonary Disease (COPD)
- Arthritis
- Depression
- Asthma
- Alzheimer’s Disease
Main Elements of Management of Chronic Care
- Personalized Care Plans: The development of comprehensive plans detailing health issues, goals, medications, and coordination with other healthcare providers.
- Medication Management: Regular review and management of medications to ensure adherence and effectiveness.
- Care Coordination: Facilitation of communication among the patient’s healthcare providers, including specialists, to ensure integrated care.
- Regular Monitoring: Continuous assessment of the patient’s health status and needs, with necessary adjustments to the care plan.
Advantages of Management of Chronic Care
- Improved Health Outcomes: Enhanced management of chronic conditions contributes to improved overall health.
- Reduced Hospitalizations: Effective care coordination can reduce emergency room visits and hospital admissions.
- Increased Patient Engagement: Patients become more involved in their care, leading to increased satisfaction and adherence to treatment plans.
Taking the First Step
- Contact Your Healthcare Provider: Discuss management of chronic care services with your primary care provider to determine eligibility and begin the development of a care plan.
- Familiarize Yourself with the Process: Be ready to provide informed consent and participate in an initial face-to-face visit to establish your care plan.
- Maintain Engagement: Keep regular communication with your care team and adhere to the agreed-upon care plan for optimal health outcomes.