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How Doctors and Medical Practices Can Effectively Develop and Manage Chronic Care Plans

Chronic care plans are an important part of how doctors and medical practices manage their patients’ health. These plans track and monitor the progress of a chronic disease or condition over time, and they help ensure that patients are receiving the best treatment possible. Having a chronic care plan in place can also help doctors prevent disease progression—and ultimately save lives!


In this blog post, we'll explore how to develop, implement, and manage effective chronic care plans. We'll discuss how they work and why they're such an important tool for doctors—and what you can do if you're interested in setting up your own plan. Let's get started!


Define the term “chronic diseases”

Chronic diseases are long-term illnesses that require ongoing care. They can be progressive and can be life-threatening, though not always preventable. Chronic diseases are often the result of genetics, lifestyle choices, environmental factors, and aging. Some examples of chronic conditions include: diabetes mellitus type 2; heart disease; asthma; arthritis (osteoarthritis); COPD/emphysema; rheumatoid arthritis; cancer

How many people in the United States are affected by chronic diseases?

  • Chronic diseases are a major health issue in the United States. More than half of Americans have at least one chronic disease, and they're the leading cause of death in our country.

  • Chronic diseases are defined as any illness lasting three months or longer — like asthma, diabetes and heart disease.

  • It's estimated that chronic diseases cost $717 billion each year in medical bills, disability payments and lost productivity (that's $1 trillion when combined with indirect costs associated with premature deaths).

What is a chronic care plan?

A chronic care plan is a document that helps patients and doctors manage the cost, risk, and quality of care for a specific chronic disease. It’s one part treatment plan and one part plan for managing costs.


That means it can help patients:

  • Manage their disease better. These plans are designed to help people with diabetes or other chronic conditions live longer and healthier lives by giving them information about how to prevent complications like heart attacks or amputations caused by high blood sugar levels. They also help patients avoid hospital visits by providing tips on self-treating certain illnesses or avoiding them altogether when possible (e.g., getting vaccinated).

  • Save money on medical bills if they start using their health insurance before they get sick again (by paying lower premiums). Even if your doctor doesn't offer a discount right away, having your care documented could lead to better rates down the line—especially if you have a pre-existing condition such as diabetes or high blood pressure that has made getting coverage difficult in the past

What components should be included in a chronic care plan?

A chronic care plan should include a list of medications, lifestyle changes, health screenings, doctor visits and tests. Medications are the most important part of the plan. The patient must be aware of the benefits and risks associated with each medication, including side effects and dosage information.

A list of lifestyle changes should be included in the chronic care plan as well. These can include diet restrictions (e.g., no red meats), exercise plans (e.g., 1 hour per day), weight loss/gain goals (e.g., lose 20 lbs.), smoking cessation plans, alcohol consumption restrictions (e.g., no more than 2 drinks per day) and other activities that need to be mentioned because they affect the disease state or treatment course (e.g., driving limitations).

Health screenings that are recommended for your condition should also be highlighted in your chronic care plan so you know when they need to take place and what type of screening it is exactly (blood work vs x-ray vs mammogram). Doctor visits can also be noted: frequency/days per month or year; whether they're required or optional; who will attend them besides yourself if there's someone else involved in your care such as family members or partners; if there's anything specific discussed at these appointments such as check-ups on how well certain treatments are working for example--anything specifically relevant should go here too!


Why should doctors and medical practices develop and manage chronic care plans?


Patients are more likely to follow their doctor’s recommendations, comply with their medication regimens, and adhere to lifestyle changes when they have a chronic care plan.

A patient who is empowered by an individualized treatment plan will be more motivated to stick with it because he or she has been involved in the decision-making process. In addition, having a clear goal can help patients better understand what they should expect from their treatment and why it’s important for them to succeed.

How do doctors form their recommendations for creating a chronic care plan?

  • The first step doctors take when forming a chronic care plan is to refer back to the patient's medical history.

  • Doctors should also consult with other healthcare professionals, such as nurses and pharmacists, who can add valuable information about your condition and treatment plan.

  • Ask your doctor if he or she will meet with you face-to-face so that you can discuss what's important to you in your chronic care plan.

Where can medical practices get help with the development and management of their patient’s chronic care plans?


There are a variety of organizations that can help medical practices with the development and management of their patient’s chronic care plans. These organizations provide tools and services that allow medical practices to effectively manage their patients’ chronic care plans. However, one of the best ways for medical practices to get help with this process is by working together. Medical practices will often pool their resources in order to provide better service to their patients, which ultimately improves patient satisfaction and increases the likelihood that patients will refer other people who need similar services.


Chronic care plans can give patients the tools they need to better manage their lifestyle changes.

  • A schedule of self-care activities like exercise or medication adherence

  • The symptoms you should look out for

  • The names and contact information of any specialists involved in their care (e.g., cardiologists, endocrinologists)

The patient must sign off on the chronic care plan before it can be implemented in her practice. While doctors and medical practices often create these documents themselves, they can also be made by the patients themselves with some help from a medical professional. Chronic Care Plans should always be updated whenever there is an update to the patient’s condition or when new events occur (e.g., surgery).



After reading this article, physicians who deal with chronic care patients should be able to develop a process that will ensure the optimal treatment of their patients while also reducing the number of patients they have to personally oversee. Anyone who follows the steps outlined here will be able to effectively manage their patients, thus improving the quality of care all around.







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