What is Chronic Disease Management & How it Will Help Your Organization

Remarkable improvements to healthcare and medicine have resulted in a substantial increase in life expectancy over the last century. For context, the average life expectancy in the United States at birth in 1910 was just 50 years. A century later, in 2010, it had risen to about 79 years.

However, although we’re living longer, we’re also living sicker. In the past 25 years, the quality of life has been on a steady decline due to the prevalence of chronic diseases. According to the CDC, over 45% of adults have at least one chronic disease, which accounts for 7 out of every 10 deaths. Worse, 4 out of 10 adults have two or more chronic diseases.

In this article, we will explore what chronic disease management is and how it can help HR professionals and organizations improve the quality of life of people living with chronic conditions. It’s especially important for HR professionals, as it is a key component of population health management, and population health analytics. We will also delve deeper into how taking a proactive, patient-centered approach to care can help reduce healthcare costs, increase productivity, and improve workforce productivity.  

• What is Chronic Disease Management?
• What are the Key Goals of Chronic Disease Management?
  • Enhancing physical, cognitive, and social functionality
  • Preventing complications and reducing the risk of hospitalization
  • Controlling and minimizing distressing symptoms
  • Delaying the progression of the disease
  • Promoting self-management and empowering patients
• What are the Core Elements of Chronic Disease Management?
• What are Chronic Disease Management Strategies?
• How will chronic disease management help your organization?
• What are the 4 unhealthy behavior choices that could lead to Chronic Disease?
• How to use a wellness program to prevent unhealthy behavior choices

What is Chronic Disease Management?

The CDC broadly defines a chronic disease as a “condition that lasts 1 year or more and requires ongoing medical attention or limits activities of daily living or both.”

Examples of chronic diseases include:                                        

• Heart disease
• Stroke
• Cancer
• Diabetes mellitus
• Obesity
• Arthritis
• Alzheimer’s and dementia
• Hypertension
• Respiratory diseases
• Oral diseases

Chronic Disease Management is “an integrated care approach to managing illness which includes screenings, check-ups, monitoring and coordinating treatment, and patient education.” In other words, this is the process of managing chronic illnesses through a combination of medical treatments, lifestyle changes, and self-care strategies.

What are the Key Goals of Chronic Disease Management?

Chronic disease management incorporates five major goals. These include:

Enhancing physical, cognitive, and social functionality

Most chronic diseases can be physically, mentally, and emotionally limiting. While some may present outward symptoms, others are more insidious, affecting the patient with invisible symptoms.

Consequently, chronic disease management aims to improve individuals’ overall quality of life by caring for the whole person. This may involve addressing physical, emotional, and social aspects of health, such as pain management, mental health in the workplace support, and social support.

For example, exercise, physical therapy, and medication management can help individuals better manage their symptoms and maintain their ability to perform essential job functions.

Similarly, cognitive-behavioral therapy can help them manage cognitive symptoms such as memory loss or difficulty with decision-making, which can impact job performance. Improving social functionality through social support and other resources can help patients maintain social connections and engage with their colleagues and the broader community. 

Preventing complications and reducing the risk of hospitalization

Most patients with a primary chronic illness are more likely to suffer from other complications like depression. “More typical is a patient with type 2 diabetes who is depressed and obese and has coronary heart disease and osteoarthritis,” observes Kevin Grumbach, MD, in an article in the Annals of Family Medicine.

Some chronic conditions lead to multimorbidity, defined as “multiple comorbidities or chronic conditions.” This is more common in adults aged 65 or older but can also affect younger patients.

Chronic disease management strategies are designed to prevent these complications through regular monitoring and management. 

Controlling and minimizing distressing symptoms

Reducing the severity and frequency of symptoms is an important goal of chronic disease management. Even though some chronic diseases may not be life-threatening, many often present ongoing symptoms that can impact daily life.

For example, a lower limb is amputated every 20 seconds due to complications of diabetes. 25.7 million of the 58.5 million US adults with arthritis suffer from arthritis-attributable activity limitation (AAAL). Additionally, over 50% of people with knee osteoarthritis will have a total knee replacement done during their lifetime.

Chronic disease management aims to reduce the severity and frequency of these symptoms through various strategies, such as dietary changes and physical activity. This helps individuals better manage their condition and experience a greater sense of control over their health.

Delaying the progression of the disease

Chronic diseases often involve the gradual progression of the condition. However, a patient’s quality of life can improve with nutritional interventions, lifestyle interventions, and medical management.

The World Health Organization defines that as rehabilitation. This process can help reduce the progression of the debilitating effects of conditions such as diabetes, chronic kidney disease, cancer, and cardiovascular disease. It also reduces hospitalizations and emergency department visits, improves functional status, and increases life expectancy.

Promoting self-management and empowering patients

Empowering patients to actively manage their chronic conditions significantly contributes to positive behavioral, emotional, and cognitive change. Some solutions include providing in-depth education about their disease, training to self-administer medication, or teaching patients how to track their symptoms and adjust their treatment plans as needed.

However, self-management can’t work in isolation. People with a robust support system often have better health outcomes. Family members or caregivers may help patients manage their medication schedules, prepare healthy meals, or accompany them to medical appointments. Healthcare providers may collaborate with the patient and their support system to develop a treatment plan tailored to their needs and preferences.

What are the Core Elements of Chronic Disease Management?

Chronic disease management falls under the chronic care model designed by Wagner et al. in the 1990s. The model operates within 6 core elements that make achieving the highest quality chronic disease care possible. These are:

1. Community resources: This involves leveraging resources available in the community to support patients with chronic conditions. These resources may include faith-based organizations, schools, support groups, and other social services. Linking patients with community resources helps them address social determinants of health and improve their overall health outcomes.
2. Health system: This involves creating a healthcare system equipped to handle patients with chronic conditions. This includes everything from implementing policies and procedures that ensure effective care coordination to leveraging health information technology to improve care quality and efficiency.
3. Self-management support: Chronic disease management involves providing patients with the tools and resources necessary to manage their condition effectively. This can be through education on healthy lifestyle choices, symptom management, and recognizing and responding to warning signs.
4. Delivery system design: This involves redesigning the healthcare delivery system to better meet the needs of patients with chronic conditions. This may include implementing care models that emphasize proactive, team-based care and developing evidence-based care protocols tailored to individual patient needs.
5. Decision support: This involves providing healthcare providers with tools and resources to help them make evidence-based treatment decisions. This may include clinical decision support tools and protocols that help providers make informed decisions about medication management, diagnostic testing, and other aspects of care.
6. Clinical information systems: This involves leveraging health information technology (HIT) to support CCM programs, such as electronic health records, telehealth, and remote monitoring devices. Implementing HIT systems helps improve communication and collaboration among healthcare team members and provide patients with more seamless and efficient care.

What are Chronic Disease Management Strategies?

Chronic disease management strategies are approaches used to support patients in managing their chronic conditions and improving their health outcomes. These strategies can be used individually or in combination, depending on the patient’s specific needs and preferences.

1. Coordinated, team-based care: This is a multidisciplinary approach involving doctors, nurses, pharmacists, and other healthcare professionals to manage the patient’s chronic disease.
2. Telemedicine: The use of telecommunication technology, such as video conferencing, electronic health records, telehealth, and remote monitoring devices to collect health data from patients and monitor their condition remotely.
3. Self-management support programs: Programs that educate patients about their chronic disease, including how to manage their symptoms, take their medications correctly and adopt healthy lifestyle practices.
4. Disease-specific programs: Programs designed specifically for patients with a particular chronic disease, such as diabetes or heart failure.
5. Collaborative care models: Approaches that involve patients, their families, and healthcare providers working together to manage the patient’s chronic disease and achieve better health outcomes.
6. Population health management: Involves identifying and stratifying high-risk patients and implementing targeted interventions to improve outcomes and reduce costs.

How will chronic disease management help your organization?

Chronic disease management can help your organization in several ways, including:

1. Improved employee health and well-being: Managing chronic conditions effectively results in better health outcomes. This can increase job satisfaction, motivation, and productivity.
2. Reduced healthcare costs: According to the CDC, 90% of the annual US $4.1 trillion healthcare spending goes to chronic and mental health conditions. Preventing complications and reducing the risk of hospitalization can help reduce healthcare costs for both the organization and employees.
3. Enhanced reputation as an employer: Demonstrating a commitment to the health and well-being of employees improves your reputation as a supportive and caring employer. This can, in turn, help to attract and retain top talent.
4. Improved employee engagement and retention: Empowering employees to take an active role in their own health and wellness improves morale. Providing support for their chronic conditions can also enhance employee engagement and reduce turnover.
5. Better use of healthcare resources: Effective chronic disease management strategies can help reduce unnecessary visits to healthcare providers and optimize the use of resources. It can also help improve the healthcare system’s efficiency and effectiveness.
6. Improved overall organizational performance: By promoting the health and well-being of employees, reducing healthcare costs, and enhancing the organization’s reputation, chronic disease management programs can improve overall organizational performance.

What are the 4 unhealthy behavior choices that could lead to Chronic Disease?

Even though most of us will suffer from a chronic disease at one point in our lives, we can delay or even prevent most illnesses. The top modifiable causes of chronic diseases are simply unhealthy behavior choices, which we can avoid with a few adjustments. These are:

1. Poor nutrition: Over 90% of adults and adolescents in the US do not eat enough fruits and vegetables per day. Their diet is high in unhealthy fats, added sugars, and salt, which can contribute to the development of chronic conditions such as heart disease, stroke, diabetes, and certain types of cancer.
2. Physical inactivity: A sedentary lifestyle, characterized by limited physical activity, increases the risk of developing heart disease, type 2 diabetes, stroke, and cancer. Unfortunately, over 50% of Americans do not get enough physical exercise, resulting in $117B in annual healthcare costs.
3. Tobacco use: Smoking and exposure to secondhand smoke are major risk factors for developing a wide range of chronic diseases. In fact, tobacco use is the leading cause of preventable disease and death in the United States, according to the CDC.
4. Excessive alcohol consumption: Excessive alcohol consumption shortens the lifespan of a drinker by a whopping 26 years! Alcohol causes 1 in every 5 deaths for people aged 20 to 49 and is responsible for $249B+ in economic costs in the US annually.

How to use a wellness program to prevent unhealthy behavior choices

A wellness program can be a powerful tool to help prevent unhealthy behavior choices and promote healthy lifestyle practices. Here are some ways a wellness program can be designed to address these behaviors:

1. Education and awareness: Provide information and resources to employees about the importance of healthy lifestyle choices. Encourage a healthy lifestyle, regular physical activity, and avoiding tobacco and excessive alcohol consumption.
2. Healthy food options: Encourage healthy eating habits by providing healthy food options in the workplace, such as fresh fruits and vegetables, whole grains, and low-fat dairy products.
3. Physical activity opportunities: Encourage physical activity by providing opportunities for employees to be active. On-site exercise classes, walking groups, or access to gym facilities can make a huge difference.
4. Employee Assistance Programs: Provide one-on-one coaching to employees to help them achieve their health and wellness goals, such as weight loss, physical activity, or quitting smoking (some employers even offer a smoking cessation program to tackle this).
5. Incentives: Motivate employees to make healthy choices by offering incentives for participating in wellness programs. These can be discounts on health insurance premiums, gift cards, or paid time off. Some employers even launch their wellness programs after testing a few workplace health promotions to gauge response.
6. Use technology to track progress and provide feedback, such as fitness tracking devices or health coaching apps. Regularly evaluate and adjust the wellness program based on participant feedback and outcomes to ensure it effectively promotes healthy behavior choices.