Disease Management and Integrated Care
One of the greatest challenges that will face health systems globally in the twenty-first century will be the increasing burden of chronic diseases. Greater longevity, increasing exposure to many chronic disease risk factors such as tobacco consumption, and the growing ability to intervene with new treatments to keep alive those who previously would have died, have changed the burden of diseases. Chronic conditions are defined by the World Health Organization as requiring ongoing management over a period of years or decades. These conditions require a complex response over an extended period of time that involves coordinated input from a wide range of health professionals and access to essential medicine and monitoring systems. The goals of chronic care are not to cure but rather to enhance functional status, minimize distressing symptoms, prolong life, and to enhance quality of life. It is clear that these goals are difficult to achieve by means of the traditional approach to health care that focuses on individual organ-directed diseases and that is built around an acute, episodic model of care and a relationship between the individual patients and the doctor.
KeywordsCOPD Disease management Integrated care Chronic disease Definitions Disease-management programs Patient-related intervention Professional-directed intervention Organizational intervention
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