4 Chronic Conditions—and Their Coordination Challenges

Coordinating a patient’s care is never simple. But when more than one chronic disease is involved, the task becomes especially complex.

If you’re a care coordinator, connecting clients to services to help manage their comorbid conditions is a big part of your job. Providing this support is about more than understanding chronic diseases individually. It means cultivating extensive knowledge on the impacts they can have in combination.

In these complex cases, the physical, social, and psychological needs of a patient are often significant. Maintaining a patient-centered perspective while tackling logistical care-related challenges is no easy feat. You may not be a physician. But you have a deep understanding of the toll that chronic diseases can take—especially when they occur together.

In this post, we’ll look at a few major complex conditions—and the challenges they can present to care coordinators.

1) Cardiovascular diseases

Cardiovascular diseases are the number one cause of death globally, according to the World Health Organization (WHO). Coronary artery disease, hypertension, stroke—these conditions are on the rise. And more and more often, they’re being managed at home. For care coordinators helping at-home clients, cardiovascular diseases pose many challenges.

First off, there’s the number of health care professionals who are often involved. It’s not just about cardiologists and the primary care physicians. A whole range of practitioners—from heart failure specialists to dieticians—are often integral to high-quality care plans.

Within these teams, communication breakdowns can occur. Patient-centered care can quickly become an afterthought. As a care coordinator, you work hard to make sure this doesn’t happen.

You may also worry about the day-to-day care that your client receives. Interactions can occur with blood pressure or cholesterol medications (especially when your client is medicated for several chronic diseases). Complications may also arise when caregivers take on minor procedures—such as dressing changes around a LVAD line.

You may not be directly responsible for these tasks. But it’s your job to ensure that there’s someone there to perform them—and perform them correctly. Doing all that you can to promote communication across circles of care is key.

2) Cancer 

Care coordinators can play a crucial role in cancer care. As with many chronic diseases, cancer often necessitates care from team members of various specialties. Without proper coordination, the combined work of an oncologist, surgeon, and primary care physician will far be less effective.

There are also many experiences unique to cancer patients that can be emotionally and psychologically difficult. Treatments such as chemotherapy can cause major bodily changes, including weight and hair loss. Often, patients require tailored counseling and social support to deal with these changes. Creating or strengthening these support networks can be challenging for care coordinators.

Lastly, when it comes to cancer, family members don’t always know what to expect. They may not be aware of how best to support their loved one during a time of monumental change. As a care coordinator, you can help through one-on-one discussions.

When a client has several chronic diseases, the complexity of cancer treatment and its effects can increase. Care coordinators should aim to improve communication not only between professional team members, but among patients, caregivers, and family members.

3) Chronic respiratory diseases

Chronic respiratory diseases such COPD, asthma, and sleep apnea can also create major coordination challenges. This is more true now than ever, as there’s a growing trend toward providing pulmonary rehab and related monitoring at home.

COPD can prove especially difficult to manage. Unfortunately, the disease is responsible for a high volume of hospital readmissions. Of course, coordinating care for COPD patients often means arranging for treatment from specialists (such as pulmonologists and respiratory therapists). The movement of much of this care into patient homes represents a relatively new delivery method—and (potentially) new coordination challenges.

Comorbid chronic conditions can further complicate care. As just one example, COPD and heart failure can exacerbate one another and make breathing very difficult.

Fortunately, there are opportunities for care coordinators to improve life for clients. New technologies—such as patient-friendly video-calling apps—are opening up new communication possibilities for respiratory therapists and patients. And innovative programs like the INSPIRED COPD Outreach Program are reducing readmission rates. By strategically embracing these new ways of delivering care, you can improve coordination for patients with chronic respiratory diseases.

4) Diabetes 

Coordinating care for clients with diabetes can be difficult due to poor compliance with medication, dietary, and lifestyle instructions.

As rates of the disease rise, patients are increasingly performing self-care activities to manage their diabetes at home. In many ways, this is a great development. Many of these patients have the opportunity to significantly improve their health.

Care coordinators can help by aiding clients with diabetes in setting reachable goals. That said, there’s a not-so-positive flipside: failing to meet these goals can lead to serious consequences.

According to a 2016 statistic, an amputation occurs every four hours due to a diabetic foot ulcer. In so many of these cases, a few steps could prevent this outcome. As an example, regular foot care appointments combined with at-home self exams can prevent ulcers from developing or worsening.

Unfortunately, clients with multiple chronic conditions must often remember increasingly complicated self-care regiments. The good news? As a care coordinator, you can connect clients to the resources they need—and drive home the importance of adhering to instructions.

Technology that makes it easy for clients to take part in their own care can provide support. By making it easy to share health information and check-in with you (and other care providers), the right mobile app simplifies self care. Diabetics and clients in need of complex care will reap the benefits.

Feature image courtesy of hobvias sudoneighm


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