Clinical Review ABC of psychological medicine

Organising care for chronic illness

BMJ 2002; 325 doi: http://dx.doi.org/10.1136/bmj.325.7355.92 (Published 13 July 2002) Cite this as: BMJ 2002;325:92
  1. Michael Von Korff,
  2. Russell E Glasgow,
  3. Michael Sharpe

    A major and increasing task for health services is the management of chronic illness. Although the details of chronic illness management will depend on the illness in question, many of the principles are common to all chronic conditions.



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    Treating chronic conditions must involve the family

    Principles of effective management

    Whatever health services may offer, most of the day to day responsibilities for the care of chronic illness fall on patients and their families. Planners and organisers of medical care must therefore recognise that health care will be most effective if it is delivered in collaboration with patients and their families. To enable patients to play an active role in their care, health services must not only provide good medical treatment but also improve patients' knowledge and self management skills. This can be done by supplementing medical care with educational and cognitive behavioural interventions. Chronic disease treatment programmes have tended to underestimate the need for this aspect of care, and, consequently, many treatment programmes have been psychologically naive and, as a result, less effective than they could have been.

    Common elements of effective chronic illness management

    • Collaboration between service providers and patients

    • A personalised written care plan

    • Tailored education in self management

    • Planned follow up

    • Monitoring of outcome and adherence to treatment

    • Targeted use of specialist consultation of referral

    • Protocols for stepped care

    Services also need to be not merely reactive to patients' requests but proactive with planned follow up. Finally, to be most efficient, interventions are best organised in a stepped fashion—that is, the more complex and expensive interventions are given only when simpler and cheaper ones have been shown to be inadequate or inappropriate.

    Collaboration with patients and families

    To win the collaboration of patients and their families, those providing care need to negotiate and agree on a definition of the problem they are working on with each patient. They must then agree on the …

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