Comprehensive Care Models: Help Your Patients Live Well with Chronic Illness

A nurse walking with her patient.

Currently, 1-in-4 Americans live with a chronic illness. A disproportionate number of those are elderly or minorities. This creates an enormous burden on our healthcare system, family structure and society. 

Our goal as healthcare advocates is to decrease the disability that is associated with chronic illness as well as improving quality of life, or to “live well.” 

Improving Life for Patients With Chronic Conditions

Let’s consider comprehensive care models that have been shown to significantly improve life for those with chronic illness: 

  • Caregiver education and support 
  • Patient-centered chronic disease self-management

Let’s focus on ways to help your patients live well. 

Get Caregivers Involved

Caregiver education and support are vital to ensuring your patient has a comprehensive, doable plan they will follow. As patients see more physicians, the complexity of the care plan can be difficult to decipher and understand, especially if the chronic illness affects the patient’s memory. 

Encourage your patient’s family members to join the patient during office visits. This allows some oversight for follow through on the patient’s care plan. Be available to answer questions and remember that the best care for your patient centers around what your patient wants and needs.  

Provide Improved Patient-Centered Care 

Patients who are involved in medical decision making (patient-centered care or shared decision making) tend to follow through with their care plan with a decrease in the use of resources.   

How can you provide better patient-centered care?

  1. Some patients want to be fully involved and others want just an outline. Don’t assume you know. Ask. A simple “How much information do you want to know?” will give you your answer.
  2. Don’t feel intimidated by patients and caregivers who ask questions. Either you missed what is important to the patient or you have not communicated effectively.  
  3. Know that everyone learns differently. Your care plan/directions need to be clear, direct and have some form of written instructions. You may need a “model” of an organ system or a handout. You may even need to sketch or draw at times
  4. Ensure understanding. Summarize frequently. Look for understanding through body language.  

Patient and caregiver participation is key in decreasing the burden of chronic illness. Let’s look at other ways that you can help your patients live well.  

Going Beyond Well-Known Lifestyle Changes

Lifestyle changes, such as tobacco cessation, exercise and diet modification, are all well-known factors in living a healthy life. What are some other ways that you can ensure your patients that they are living well?  

  1. Insomnia. Many sleep disorders are prevalent among patients with chronic illness and can be caused by psychiatric disorders, such as anxiety or depression. Sleep disorders can also be a side effect of medications. Lack of restful sleep can lead to major health issues and fatigue, so investigate the cause of insomnia and don’t hesitate to treat it. 
  2. Understand the barriers to your patient taking action and living a healthy lifestyle.  Barriers include time constraints, habits, lack of support, knowledge deficiencies, anxiety and depression. If you can identify the barrier, you can problem-solve a solution. 

Help Your Patients Live Well

To really create change and improve the quality of life for patients with chronic illness, many factors must align. It can require more than recommending a healthy diet or increased exercise.  

Start with engaging patients and their caretakers and then provide accurate, simple to understand information that aligns with the patient’s goals. Consider how insomnia, fatigue and barriers create a pattern of inaction and take steps to counteract these issues. 

A healthier happier patient awaits you. 


For more tips to help engage, empower and connect with your patients, follow us on Twitter, Facebook, Instagram and LinkedIn.

Raenali Publications® is a leading provider of innovative, physician-directed patient education in the field of nephrology.

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