Chronic disease is a profound medical challenge in the United States. Millions of people that have prolonged conditions struggle to carry out basic tasks of daily life. Countless individuals fail to receive adequate care from a system geared toward managing symptoms and acute illness. More than two-thirds of our country’s healthcare costs focus on treating chronic disease. Each disease is often complicated and challenging to navigate from a medical provider standpoint efficiently. Ailments such as COPD, Coronary Artery Disease, and cancer are progressive in nature, requiring regular surveillance and flexibility to ensure the best care.

Chronic conditions can multiply as individuals age. They compromise peoples’ ability to perform routine activities of daily living, decrease independence, and erode overall quality of life. Traditional western medicine treats the illness instead of the whole patient and is often expensive. This model focuses squarely on the physiological aspects of the condition. Departing from this paradigm, and shifting towards a system that incorporates a multi-pronged approach can provide holistic care that will prove to be more efficacious. A multi- disciplinary team facilitating comprehensive care elements that address a client’s physiological, psycho-social, and spiritual requirements, as well as advocacy, can meet this need.

The first member of a well-functioning chronic care team should be a primary care provider. Start with a physician who specializes in family or internal medicine.  A mid-level provider, such as a physician assistant or nurse practitioner, can also assume this role.  This individual will serve as the gatekeeper, coordinating treatment, check-ups, screenings, patient education, and generating the necessary referrals to proper specialists and ancillary services.   When choosing this person, make inquiries to friends, family, neighbors, and co-workers as to who they utilize, and find out how effective they feel their care is.

Many healthcare organizations have physician referral lines geared to help individuals establish care if they are new to the community or their previous provider has re-located. These are beneficial to find out which physicians are accepting new patients. Keep in mind that employees are not allowed to make physician recommendations within their healthcare system due to regulatory policies. Once this team leader has been chosen, they will evaluate previous medical history, assess current health status, and schedule preliminary tests. Recommendations will follow, and will usually begin with medication and lifestyle changes.

Medicine and healthy lifestyle choices, such developing consistent exercise and healthy eating habits, work together. Many people with chronic disease fail to understand this concept, and falsely assume they can choose the one that is preferable to them and disregard the other. The physician recommends medication and lifestyle modification together because consistently following both will produce the best results regarding symptom management. If you’re living with chronic pain or dealing with any chronic disease, you should consider joining a support group for an opportunity to connect with people who have gone through the same conditions.

For individuals needing a major overhaul of their eating and physical activity habits, referrals to a dietitian and a medical exercise program or clinical exercise professional may be appropriate. For those having difficulty with their medication regimen, a consultation with a pharmacist can help. Some healthcare systems offer disease-specific education programs that instruct clients in evidence-based self-management. Individuals learn problem-solving skills to help them gain confidence and can better partner with their medical team in managing their illness.

Once these self-care “homework assignments” have been initiated, referrals to specialists offering more intensive, condition-specific therapeutic treatments and procedures can be ordered. Rheumatologists and endocrinologists are two examples of disease-specific specialists trained to give more targeted care and even interviewed in a specific way provided at Once the physiologic aspect of care has begun to be addressed, the psychosocial segment can be evaluated.

People suffering from the chronic disease often have a substantial symptom burden to bear. Carrying this load long term frequently leads to emotional strain that manifests itself through anxiety and depression. The primary care physician addresses these psychological issues. Having an avenue to express pessimistic feelings is important, and can help prevent downward mental health spirals that negatively influence physical condition. A care team that includes a licensed mental health professional as a member can aid in this area by offering a trained clinician to serve as a sounding board for venting and “offloading” these emotions. This therapist can educate clients and families about behavior modification and stress management techniques designed to help deal with negative feelings.

Cognitive Behavioral Therapy is a particular method that can be used by a mental health provider to help clients better cope with difficult issues and put them in perspective. One critical aspect of the psycho-social equation that is often overlooked is spiritual needs. Many individuals dealing with chronic conditions including chronic pain and depression have deep spiritual needs. Regardless of the individual’s belief system, addressing these requirements is central to helping them to develop useful coping strategies. Having access to a pastor, rabbi, priest, imam or other spiritual leader connected to the person’s faith will give them comfort by having an opportunity to disclose fears, share experiences, and pray or meditate.

Talking through worries and concerns with a faith leader and getting a spiritual perspective can be effective for some in bringing about a sense of calm and acceptance of their situation. Reading and discussing that religion’s text can provide comfort and a renewed sense of emotional strength. It may also help the individual to emotionally release hold of situations that they have little control over. Having a designated advocate is the final piece of the chronic disease management puzzle, and is one that is frequently neglected.

An appointed advocate is an individual with the responsibility to help gather and understand information to aid the disease sufferer in making care decisions. This person is often a close family member or friend and is sometimes a healthcare professional who knows their way around the system. The advocate functions as a liaison between the patient and the medical professionals providing care, ensuring consistent communication and understanding of care options and delivery. In situations where the person has been admitted to the hospital, it can be a case manager or social worker that functions to coordinate care during and after the hospital stay. The advocate may be charged with making phone calls, setting up appointments, arranging transportation and executing a durable power of attorney should the need arise.

Successful healthcare management of chronic disease requires an integrated approach. Coordination of treatment, ensuring patient and family education, discussing psycho-social and spiritual needs, and providing prompt assistance through advocacy are all vital elements. The overall goal is to address and facilitate treatment in each area while fostering self-care. Recently created programs like Medical Home, Medicare CCM, and Stanford’s Chronic Disease Self-Management program strive to control costs and deliver care that is comprehensive and family-centered, aiding people with chronic disease in learning how to self-manage their condition. A multi-disciplinary focus supports communication, contains costs, expedites care, and places the individual and the team in the best position to effectively treat the condition.

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