Chronic care management

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]

Chronic care management is an approach to improving health care for people with chronic disease, giving an active role to the patient. Its essence is to help patients to maintain independence, through ongoing education, motivation and habitualization of patients that have chronic diseases such as diabetes, heart failure, chronic pulmonary obstructive disease, rheumatic diseases (rheumatoid arthritis, severe osteoarthritis), and many other diseases. This term is equivalent to disease management for chronic conditions.

Frequently the treatments for such diseases are complicated and difficult for patients to comply with. Patients need to be educated on the benefits of treatment and the risks of not properly following their treatment to motivate them to comply. Chronic care management helps patients systematically monitor their progress and coordinate with experts to identify and solve any problems they encounter in their treatment. Fragmentation of care is a risk for patients with chronic diseases, because multiple chronic diseases coexists frequently.