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Chronic Disease Management

Physical therapy programs for our patients are designed to relieve pain, promote healing, and restore function and movement.

At Specialized Home Care, we understand how Chronic disease management affect the way you feel and your day-to-day activity level. Chronic conditions such as COPD, congestive heart failure, Parkinson’s or diabetes are serious conditions and we work to ensure the best possible and most thorough care for your diagnosis.

We treat all our patients on an individual basis and will customize your rehabilitation program to focus on any one or a combination of:

  • Chronic Pulmonary Disease (COPD)
  • Congestive Heart Failure
  • Diabetes
  • Parkinson’s and other Neurological Disorders
  • CVA and Stroke Recovery


At the core of our chronic condition and disease care are the specialists we connect you with to ensure optimal recovery.  These specialists include:

  • Clinical Specialists in Respiratory Therapy
  • Registered Nurses
  • Physical Therapists
  • Occupational Therapists
  • Parkinson’s Certified Clinicians


Our specialized home care support services for disease management include:

  • Smoking Cessation
  • Lifestyle Changes
  • 24-hour Response for Emergency Management
  • Nutritional Counseling.  

What Is Chronic Disease Management?

Chronic disease management is a coordinated care approach focusing on improved health outcomes and quality of life for patients with chronic diseases. This coordinated chronic disease care approach includes different procedures such as health screenings, medical check-ups, health monitoring, treatment coordination, and patient education, according to the Health Insurance Marketplace of the Department of Health and Human Services. These components can improve the quality of the patients’ lives and reduce healthcare costs. Chronic disease management aims to prevent and minimize the symptoms attributed to chronic diseases.

Many chronic diseases affect millions of people in the United States. These include the following:

  • Cardiovascular disease
  • Diabetes
  • Osteoporosis
  • Arthritis
  • Multiple sclerosis
  • Pulmonary disease
  • Congestive heart failure
  • Lupus
  • Asthma
  • Crohn’s disease
  • Ulcerative colitis
  • Hypothyroidism/Hyperthyroidism
  • Alzheimer’s disease
  • Heart disease
  • Cancer
  • Cystic Fibrosis
  • Amyotrophic lateral sclerosis (ALS)


The National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP) states that heart disease, cancer, and diabetes are the leading causes of death and disability in the United States. The United States spends $4.1 trillion on annual health care costs, of which 90% goes to people with chronic health conditions, according to the Centers for Medicare and Medicaid Services (CMS).

Importance Of Chronic Disease Management

The Centers for Disease Control and Prevention (CDC), through the National Center for Chronic Disease Prevention and Health Promotion (NCCDPHP), released some facts and figures about chronic diseases that will show the importance of chronic disease management. Data shows that six out of ten Americans live with at least one chronic disease. Chronic diseases such as heart disease, stroke, cancer, diabetes, obesity, arthritis, Alzheimer’s disease, epilepsy, and tooth decay are the leading causes of death and disability in the United States and also the leading driver of healthcare costs. Healthcare costs can be reduced through chronic disease management, according to CDC. CDC is the leading science-based, data-driven service organization that aims to protect public health in the United States.

The importance of chronic disease management for patients with chronic diseases is that it empowers them to manage their disease and prevent complications. Managing disease and preventing complications are ensured by the health care providers working with patients. Patients can feel better and secure as the progression of their diseases is slowed down.

Another importance of chronic disease management is that it reduces the costs of healthcare services, especially for low-income adults. Healthcare services can be more expensive, especially for low-income adults when complications from these chronic diseases occur. Identifying and treating chronic diseases quickly and effectively can not only improve the conditions of patients but also reduce healthcare costs.


What Are The Goals Of Chronic Disease Management?

A study published in the International Journal of Integrated Care mentions the goals of chronic disease management. The first goal is to identify people who are at risk for one or more chronic conditions. The second is to promote self-management by patients. And the other goal is to address long-term illnesses or conditions with maximum clinical outcome, effectiveness, and efficiency regardless of treatment settings or reimbursement patterns.

The study and systematic review further suggest another goal of chronic disease management which is focused on patient participation and compliance. Patient participation and compliance are achieved with chronic disease management by enhancing the quality of life of the patient. The quality of life of the patient is measured in clinical outcomes, self-reported health status or functional status. Patient participation and compliance are also achieved by delaying or alleviating comorbidity and acute complications.


How Does Chronic Disease Management Work?

Chronic disease management works through chronic disease management programs. Chronic disease management programs focus on preventing exacerbations and complications brought on by chronic illnesses in patients. Patients can achieve improvement in health and quality of life using chronic disease management programs. Chronic disease management programs also use evidence-based practice guidelines and patient empowerment methods in evaluating clinical, economic, and humanistic outcomes.

Chronic Disease Management involves several key components. The first one is determining target audiences. Determining target audiences involves identifying which chronic diseases will be included. Once the list of chronic diseases is established, the next is to determine how the patients with these diseases will participate in the chronic disease management program. Chronic disease management programs also need to establish proven practice guidelines for managing long-term conditions.

The next key component of chronic disease management is building collaborative practice models. Building collaborative practice models with government, nonprofit, and community-based organizations enables the medical team that consists of nurses, pharmacists, dieticians, and other health care professionals to benefit from these services.

Another key component of chronic disease management is educating the patient. Educating the patient is a requirement in designing a program. This program is for personal management education for patients. Patients will learn how to manage their chronic diseases.

One more key component is measuring outcomes. Measuring outcomes involves monitoring costs, establishing procedures for the purpose of use, and health outcomes. Measuring outcomes also includes feedback and reporting.


Benefits Of Chronic Disease Management

Chronic disease management programs have several benefits. The first benefit is that it improves the safety and quality of care. Improving the safety and quality of care is crucial in making the overall quality of life of patients better.

The next benefit of chronic disease management programs is that it improves access to care. Access to care can be difficult physically or financially for patients suffering from chronic diseases. Patients can maximize access to care in order to achieve the best possible health outcome for themselves.

Another benefit of chronic disease management is that it improves patient self-management. Patient self-management support is an integral part of effective chronic illness care and improved patient outcomes, according to a study published in the American Family Physician journal. The study also states that family physicians can support patient self-management by structuring patient-physician interactions, making office environment changes, and providing education individually and through available community self-management resources.

The next benefit of chronic disease management is that it improves financial cost containment without sacrificing quality or patient satisfaction. Financial cost containment is an important strategy for reducing costs and controlling current and future costs. Reducing costs through chronic disease management is effective because it reduces healthcare costs due to complications.

One more benefit of chronic disease management is that it enhances efforts to provide health improvement programs on a population basis. Health improvement programs focus on multiple aspects of patient care and maximize the health status of defined patient populations. Chronic disease management programs coordinate care for the disease among all healthcare providers, physicians, pharmacists, hospitals, and laboratories.


Chronic Disease Management Examples?

There are several chronic disease management examples. The first example is asthma management. Asthma and other pulmonary disease management can be handled by a trained pharmacist. A trained pharmacist can provide educational programs to patients about the disease, conduct a periodic review of the patient’s inhaler technique, perform ongoing monitoring of peal-flow function tests, and manage chronic medication use, including compliance assistance.

Another example of chronic disease management is diabetes management. Diabetes management can be performed by a pharmacist. Pharmacists can provide educational programs to patients about the disease, monitor self-tested and laboratory-tested blood glucose levels, visit and educate patients on using a home blood glucose level monitoring equipment, monitor patient compliance with prescribed therapies and scheduled clinic and laboratory appointments, screen for drug interactions and adverse drug reactions, and provide medication management and review.

The next example of chronic disease management is hypertension and cholesterol management. Hypertension and cholesterol management can also be performed by a pharmacist. Pharmacists can educate patients about these silent diseases, monitor compliance with medications, diet, and exercise regimens, screen for drug interactions and adverse drug reactions, perform periodic blood pressure checks, and perform periodic cholesterol level checks.


Does Chronic Disease Management Really Work?

Yes, chronic disease management works in reducing healthcare costs and improving quality of life. A study and systematic review published in the Journal of the American Medical Association shows that intensive chronic disease management program interventions for adults that are focused on healthy behavior change are effective in minimizing healthcare costs for adult patients with type 2 diabetes. Adult patients with type 2 diabetes can benefit from programs and measures that are centered on diet, exercise, and weight loss.

However, the effectiveness of chronic disease management on health behavior long-term changes for patients with type 2 diabetes was not successful after the chronic disease management program interventions for patients. After the program, researchers found that Medicare Part B increased by $513 more. The increase in Medicare spending suggested that adult patients who were part of the chronic disease management program grew older and faced the development of other health challenges.

For chronic disease management working on improving the quality of life, the Health Insurance Marketplace of the Department of Health and Human Services identified its several critical components. the first one is screenings. Screenings help in the identification of chronic disease risk factors and early disease detection. This component contributes to the decrease of chronic disease burden and protects and promotes the health of older adults.

The next critical component is checkups. Checkups are essential in improving the control of chronic diseases and reducing the likelihood of their occurrence. This is achieved when healthcare providers routinely remind their patients about the risks and the process of managing their health.

Another critical component is coordinating treatment. Coordinating treatment is when healthcare providers and organizations collaborate to produce significant improvements in managing chronic diseases. 

For more information about Chronic Disease Management contact Specialized Home Care today.

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