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Chronic Care Management Priorities for a Newly-Diagnosed Patient

A chronic condition diagnosis can be an overwhelming experience.  Not only must the patient understand and accept what it means to have a long-term health issue, but there are specific actions that the patient must take to ensure their future well-being.

Educating patients early in their disease journey is a critical step to ensure your chronic care management program achieves clinical and financial success. So how can you design programs that effectively support the needs of the newly diagnosed? The key is to help patients develop a manageable and actionable chronic care management plan (also known as a health action plan) that makes condition maintenance a component of their day-to-day life but not the all-consuming focus.

There are several elements that make up what we refer to as a health action plan. By breaking these elements into categories and prioritizing them, it can help make managing a new diagnosis of a chronic condition feel less daunting. Here are the key health action priorities for someone with a new condition:

1. Understand the key symptoms and features of the chronic condition 

The first step is to educate the patient about their condition. Provide them with clinical information on their condition from a reputable health information source or refer them to additional resources available through their health plan, healthcare provider, or pharmacist. Teach patients to familiarize themselves with the signs and symptoms associated with the condition so they can be prepared to recognize them when they occur.

2. Determine the chronic condition’s treatment plan.  

Encourage patients to establish a treatment plan with their doctor and discuss options, including any medicines that work with the condition and the side effects. Educate them about routine appointments, tests, or procedures associated with the condition. Once they are comfortable with an established treatment plan, help them to commit to it.

3. Implement lifestyle changes that reduce or improve condition symptoms.

Educate the patient on the lifestyle changes that may improve signs and symptoms associated with the condition. This may be anything from maintaining a healthy diet to increasing physical exercise or getting more sleep. Ask them to choose one lifestyle change that sounds most achievable. Provide tips on how to be successful and refer them to available health and wellness programs. Help them tackle one lifestyle change at a time. As they say, don’t bite off more than you can chew.

4. Keep a calendar to help manage appointments and maintain medication adherence.

Whether it’s an appointment book or wall calendar, a web-based platform or an app–help them choose a medium with the tools and resources that are easiest for them to navigate. Keep them organized. Educate the patient on the regular or routine tests needed for their condition, and help them schedule and note appointments, tests, and procedures. If they need to take a medication regularly, suggest a reminder tool.

5. Know the danger signs of the chronic condition. 

Familiarize the patient with any warning signs or symptoms of the condition that may require immediate attention. Encourage them to formulate a plan for what to do in the event these signs or symptoms occur. Encourage them to discuss this plan with people close to them so they know how to assist when an emergency occurs. Help them track symptoms, actions taken, and responses so they know in the future what works best for them.

6. Be an active participant in decisions about care.

It’s helpful to know what your choices are when it comes to treating and managing a chronic condition. Direct patients to shared decision making tools and encourage them to share their personal preferences with their healthcare provider so they can agree to a plan of care that is right for their situation. Help them prepare for appointments by discussing all the questions they have and suggest they make a list. Understanding how to make the most of office visits and how different healthcare providers can help is essential to empowering patients to take charge of their health.

Learn how Health Dialog approaches chronic care management program implementation.

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