Chronic Disease Management

Chronic diseases are the leading cause of death and disability in the United States. They also are a key reason for rising healthcare costs.

• Eight of ten adults 65 and older have at least one chronic condition and approximately seven in ten have two or more.
• People affected by multiple chronic conditions are at risk of early mortality, poor functional status, and hospitalization.  They also face significant out-of-pocket expenses for healthcare and prescription drugs.

Our goal is to help providers with the prevention and management of chronic diseases by supporting providers in preventing cardiovascular events, promoting tobacco cessation, improve the management of diabetes to decrease diabetes complications, identifying people at high risk for developing diabetes and chronic kidney disease. We have also included patient and family engagement and advance care planning as elements in chronic disease management.

Healthy behaviors directly contribute to positive health outcomes. Chronic disease self-management education programs also impact the development of long-term change for a healthy lifestyle. Improving health outcomes related to chronic conditions must be a joint effort between the healthcare professionals, the community, and the individual. From identifying at-risk individuals to providing self-management education and support, every individual contributes to and benefits from a collaborative approach.

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