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Thriving Beyond Diagnosis: The Art of Chronic Disease Management

By: Renee Dain, SVP, Strategic Partnerships and External Affairs
Joyce Falkenhan, DNP, RN, B-C, CNRN, Consultant for Community First Programs 
Anne Conway, RN, BSN, MS, CCM, Director of Health Plan and Hospital Services 

Chronic Disease Management (CDM) is the comprehensive and ongoing medical care, treatment, and attention required for health conditions that persist for one year or more. These conditions often limit activities of daily living and necessitate continuous medical intervention, including treatment regimens and medication. Additionally, individuals with chronic diseases may face an increased risk of developing other long-term health issues.  

Care coordination plays a pivotal role in CDM by ensuring that healthcare services are well-organized, efficient, and tailored to the specific needs of individuals with chronic conditions. Care coordinators can bring together various healthcare providers, specialists, and support services to work collaboratively. This integration ensures that different aspects of a patient’s care, from medication management to lifestyle interventions, are aligned and cohesive. It’s also vital that the individual is involved in their own care. Effective care coordinators empower individuals with chronic diseases by providing them with information, education, and resources to actively participate in decision-making regarding their health. This can enhance adherence to treatment plans and improve overall outcomes. 

We recently sat down with Joyce Falkenhan, DNP, RN, B-C, CNRN, RN Consultant for Community First Programs at The Coordinating Center and Anne Conway, RN, BSN, MS, CCM, Director of Health Plan and Hospital Services to learn more about CDM.  

What are the risk factors associated with CDM?
Risk factors for chronic diseases can be divided into nonmodifiable and modifiable categories. Nonmodifiable risk factors, inherent and unchangeable, include age, with the risk of many chronic diseases increasing over time; race, where certain ethnicities may exhibit a higher predisposition to specific chronic conditions; gender, as some chronic diseases affect men and women differently; and family history, where genetic factors and family health history contribute to an individual’s susceptibility to certain chronic conditions. On the other hand, modifiable risk factors can be influenced through lifestyle choices. These include smoking, a significant risk factor for various chronic diseases such as cardiovascular diseases and certain cancers; excessive alcohol consumption, which can contribute to liver diseases and other health issues; being overweight or obese, crucial in preventing and managing conditions like diabetes, heart disease, and musculoskeletal disorders; physical inactivity, linked to the development and progression of several chronic diseases; and poor dietary choices, high in saturated fats, sugars, and low in essential nutrients, which can increase the risk of chronic conditions, including diabetes and cardiovascular diseases. Understanding and addressing these risk factors are integral to effective chronic disease management, allowing for targeted interventions and lifestyle modifications to mitigate risks and improve overall health outcomes. 

What are some prevalent chronic diseases that require long-term management?
Numerous prevalent chronic diseases demand sustained attention and long-term management due to their persistent nature. Examples of such conditions include diabetes, where both Type 1 and Type 2 necessitate continuous monitoring and control of blood sugar levels through medications, dietary adjustments, and lifestyle modifications. Hypertension, or high blood pressure, often requires prolonged medical intervention and lifestyle changes to regulate blood pressure and diminish the risk of cardiovascular complications. Cardiovascular diseases, encompassing conditions like coronary artery disease, heart failure, and chronic heart ailments, typically demand ongoing management through a combination of medications, lifestyle adjustments, and, in certain instances, surgical interventions. This consistent and comprehensive approach to chronic disease management is crucial for enhancing patients’ well-being and preventing complications associated with these enduring health conditions. 

Why is Chronic Disease Management Important?
Taking care of chronic diseases is really important because it helps people living with long-term health issues live better lives. It involves giving regular medical attention, keeping an eye on things, and acting quickly when needed. This helps control symptoms, avoid problems, and make overall health better. Besides helping individuals, it also makes the healthcare system work better by preventing lots of hospital visits and emergencies. This helps save resources and money. Chronic disease management also deals with how different health problems can be connected, stopping more issues from happening. It’s about putting the person at the center of their care, so they can learn, make changes in their life, and get support. This doesn’t just lead to better health; it also gives people a feeling of control and well-being. So, taking care of chronic diseases is like a smart plan that helps everyone – the person and the whole healthcare system. 

 Join Joyce Falkenhan and Anne Conway on January 16, 2024, at Noon, for a special webinar on Chronic Disease Management. Click HERE to register to attend. This webinar is part of The Coordinating Center’s new Community Enrichment Series – engaging workshops supporting individuals and families to achieve their aspirations for a meaningful life! 

 Joyce Falkenhan, DNP, RN, B-C, CNRN, has 45 years of experience in health care and has been with The Coordinating Center for two years. As RN Consultant for Community First Programs at The Coordinating Center, Joyce is responsible for providing consultation, health and community care expertise and direction, as well as education and mentoring for members of the CFP team. She provides input into client-specific care and home care coordination to enable individuals with complex health care needs to safely live in the community. 

 Anne Conway, RN, BSN, MS, CCM, has 20 years of experience in health care and has been with The Coordinating Center for three years. As Director of Health Plan and Hospital Services at The Coordinating Center, Anne is responsible for the oversight, and management of care management and care coordination service programs for health plans and hospitals.   


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