Case Management

Tip: Effectively manage chronic illnesses to prevent readmissions

Case Management Weekly, April 25, 2012

Healthcare professionals need to reframe their assumptions about preparing patients for self-care. Patients must be well-prepared to take the lead once the formal clinical care process ends. They need to be armed with knowledge and proven techniques for managing their health. In addition, healthcare professionals should develop mechanisms for truly partnering with patients and their caregivers in the clinical care process.

This becomes even more important when the patient has chronic disease. The Chronic Care Model, developed by the MacColl Institute, “identifies the essential elements of a healthcare system that encourages high quality chronic disease care.”

These elements include the community, the healthcare system, self-management support, delivery system design, and decision support and clinical information systems. Each element includes evidence-based concepts that improve the chronic care process. Use of the model can “foster productive interactions between informed patients who take an active part in their care and providers with resources and expertise.

This week’s tip is adapted from Reducing Readmissions: A Blueprint for Improving Care Transitions, published by HCPro, Inc.


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