Chronic care management encompasses the oversight and education activities conducted by health care provider to help patients with long term illness and health conditions such as diabetes, hypertension, lupus, multiple sclerosis, and stopping of breathing during asleep learn to understand their condition and live successfully with it.
Research has shown that highly fragmented care for Medicare beneficiaries with multiple chronic conditions are more likely to present in emergency rooms and be admitted than others.
Chronic care management helps patients systematically monitor their progress and coordinate with experts to identify and solve any problems they encounter in their treatment.
Considering the diverse nature of chronic health problems and the roles that psychosocial environments play in their course, a purely biological model of care is usually inadequate.
A study across multiple healthcare organizations has shown promising results through embracing the role of community health workers to assist vulnerable populations improve chronic disease management and care.
Evidence-based change concepts under each element, in combination, foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise.
[13] Partnership for Solutions, a Johns Hopkins/Robert Wood Johnson collaborative, conducts research to improve the care and quality of life for individuals with chronic health conditions.
[14] J. O. Prochaska and his colleagues, investigating issues associated with the treatment of addictions, have described a transtheoretical model of behavior change as a process rather than an event.
Fennell says people commonly experience four phases as they learn to incorporate their changed physical abilities or psychological outlook into their personality and lifestyle: Crisis, Stabilization, Integration, and Resolution.
[18] The Flinders Human Behaviour & Health Research Unit (based in Adelaide, South Australia) has developed the Flinders ProgramTM, a generic set of tools and processes that allows for assessment of chronic condition management behaviours, collaborative identification of problems and goal setting leading to the development of individualised care plans with the goal of raising the quality of life for people living with chronic disease.