MANAGING CHRONIC DISEASE Questions and
Answers
Paradigm Shift
-Traditionally, healthcare was reactive, meaning it primarily responded to acute illnesses or injuries after
they occurred. Over time, the focus has shifted toward proactive care, which emphasizes health
promotion, disease prevention, and managing chronic conditions before they become severe.
-In modern health sciences education, this shift is reflected in the four spheres of care, which represent
the comprehensive approach to patient health:
4 Spheres of Care
1. Wellness, Disease Prevention
2. Chronic Disease care
3. Regenerative/Restorative care
4. Hospice/Palliative care
Expanded program support (Chronic Diseases)
▪ Programs to support chronic disease prevention and management of chronic diseases have grown
▪ The “medical home” model of care expanded the role of advance practice nurses and physicians'
▪ Services such as transitional care, self-management education, nutritional consults and others are now
funded through CMS (center of medicare and medicaid services) and private insurance
Healthcare Challenges
-A majority of leading causes of death are related to chronic disease (e.g Heart Disease, Diabetes,
Cancer, Chronic Lung Disease, Stroke, Alzheimer's, Chronic Kidney Disease)
Stats
• Six in ten adults have a chronic disease
• Four in ten adults have two or more
Self-Management Support (Chronic Disease Management)
• For effective health management, patients need basic information about their
disorder, assistance with management skills and ongoing support from the healthcare team, family,
and community
• Self-management education (SME) are self-empowerment programs that provide information for
patients about chronic conditions and how to maintain the highest quality of life while managing the
disease
, • SME programs are proven to reduce symptoms and improve feelings of control over chronic
conditions
Delivery System Design (Chronic Disease Management)
Delivery of care requires:
1. Follow-up visit as part of standard procedure
2. Determination of needs, based on condition
3. Centralized, current information about the patient’s status
4. “Group visits” provide opportunities for patients to meet with other patients with similar health
issues
• RNs are cross-trained to provide care via standing order
Decision Support Tools (Chronic Disease Management)
• Treatment decisions should be based on explicit, evidence-based guidelines that are easily accessible
to providers
• Primary care providers should be included in the care team when patients require specialty care
-Clinical information systems must include a registry of individual patients
- All members of the care team should use the registry to guide treatment, anticipate
problems and track progress of individual patients
Community Support (Chronic Disease Management)
• Community programs and organizations that can support care for chronically ill patients and expand
awareness of prevention strategies are often overlooked
• Health care organizations should form alliances and partnerships with local agencies, schools, faith
organizations, community leaders, businesses and clubs
COPD
Pulmonary disease with systemic effects:
COPD primarily affects the lungs but can also impact other parts of the body (extrapulmonary
effects) such as the heart, muscles, and metabolism, which makes the illness more severe.
Airflow limitation:
People with COPD have difficulty moving air in and out of their lungs.
This limitation is not fully reversible, meaning medications may help but cannot completely restore
normal airflow.
COPD is usually progressive, so symptoms worsen over time.
Abnormal Inflammatory response:
Answers
Paradigm Shift
-Traditionally, healthcare was reactive, meaning it primarily responded to acute illnesses or injuries after
they occurred. Over time, the focus has shifted toward proactive care, which emphasizes health
promotion, disease prevention, and managing chronic conditions before they become severe.
-In modern health sciences education, this shift is reflected in the four spheres of care, which represent
the comprehensive approach to patient health:
4 Spheres of Care
1. Wellness, Disease Prevention
2. Chronic Disease care
3. Regenerative/Restorative care
4. Hospice/Palliative care
Expanded program support (Chronic Diseases)
▪ Programs to support chronic disease prevention and management of chronic diseases have grown
▪ The “medical home” model of care expanded the role of advance practice nurses and physicians'
▪ Services such as transitional care, self-management education, nutritional consults and others are now
funded through CMS (center of medicare and medicaid services) and private insurance
Healthcare Challenges
-A majority of leading causes of death are related to chronic disease (e.g Heart Disease, Diabetes,
Cancer, Chronic Lung Disease, Stroke, Alzheimer's, Chronic Kidney Disease)
Stats
• Six in ten adults have a chronic disease
• Four in ten adults have two or more
Self-Management Support (Chronic Disease Management)
• For effective health management, patients need basic information about their
disorder, assistance with management skills and ongoing support from the healthcare team, family,
and community
• Self-management education (SME) are self-empowerment programs that provide information for
patients about chronic conditions and how to maintain the highest quality of life while managing the
disease
, • SME programs are proven to reduce symptoms and improve feelings of control over chronic
conditions
Delivery System Design (Chronic Disease Management)
Delivery of care requires:
1. Follow-up visit as part of standard procedure
2. Determination of needs, based on condition
3. Centralized, current information about the patient’s status
4. “Group visits” provide opportunities for patients to meet with other patients with similar health
issues
• RNs are cross-trained to provide care via standing order
Decision Support Tools (Chronic Disease Management)
• Treatment decisions should be based on explicit, evidence-based guidelines that are easily accessible
to providers
• Primary care providers should be included in the care team when patients require specialty care
-Clinical information systems must include a registry of individual patients
- All members of the care team should use the registry to guide treatment, anticipate
problems and track progress of individual patients
Community Support (Chronic Disease Management)
• Community programs and organizations that can support care for chronically ill patients and expand
awareness of prevention strategies are often overlooked
• Health care organizations should form alliances and partnerships with local agencies, schools, faith
organizations, community leaders, businesses and clubs
COPD
Pulmonary disease with systemic effects:
COPD primarily affects the lungs but can also impact other parts of the body (extrapulmonary
effects) such as the heart, muscles, and metabolism, which makes the illness more severe.
Airflow limitation:
People with COPD have difficulty moving air in and out of their lungs.
This limitation is not fully reversible, meaning medications may help but cannot completely restore
normal airflow.
COPD is usually progressive, so symptoms worsen over time.
Abnormal Inflammatory response:
