Chronic Disease Management
The multidisciplinary team, including a family nurse and/or pharmacist, will provide planned visits, coordinated care, counseling, and follow-up for patients with chronic illness and complex care.
Chronic diseases are conditions that are rarely if ever cured, and therefore must be correctly managed to ensure they do not worsen. These conditions can have an impact on the physical, mental, and emotional health of patients making daily management routines difficult to follow.
Therefore, it is important that patients with chronic diseases fully understand their disease and have the resources and supports to manage it correctly. Patients must take actions to maintain health at home, between visits with health professionals. This can include actions such as staying active, eating healthy, and following medical instructions.
In order to make these things easier for patients, the PCN can provide information to patients about their disease as well as assistance in dealing with disease management strategies.