Fundamentals of Chronic Condition Management

1. Defining Chronic Condition Management and Identifying Barriers

This chapter looks at the definition of chronic condition management and how chronic conditions have changed in the last few decades. We will look at examples of chronic conditions as well as statistics about chronic conditions in the United States. This chapter also reviews patient, clinician, and system barriers. With this knowledge, the health care provider can continually assess for actual or potential obstacles to success.

2. Chronic Condition Management Models

This chapter discusses the evolution of chronic condition care and reviews chronic condition management models and best practices. Strategies to improve care of patients with multiple chronic conditions will be discussed. A patient case scenario will be introduced for review and consideration.

3. The Patient-Clinician Partnership

Patient self-management is the primary goal of the support system of caregivers and the health care team. Communication with vulnerable patients and addressing special population needs will be reviewed. Customized and personalized care that is patient centered will de discussed. The patient case scenario introduced in the prior chapter will be developed as an exemplar.

4. Tools for the Patient-Clinician Partnership

After the clinician has assessed the patient and the support system, a holistic plan needs to be developed. This chapter provides practical tools for the clinician to use to partner with the patient in his/her efforts to manage chronic conditions. This chapter will integrate information from prior chapters for clinicians to be able to apply the concepts presented to their practices and at their organizations.