Chronic Care in Ambulatory Settings

Abstract

This article describes chronic care management in ambulatory settings and strategies for integrating care across treatment settings to increase efficiency and improve the quality of chronic care. Chronic care management should be client focused, recognizing the client as the primary care manager and promoting educated participation in shared decision making; care must be integrated across health and social service provider settings through case management and advanced information technology; methods must be used for identifying those who are at risk of disability progression and high-cost care; treatment protocols are needed to plan and monitor care and improve outcomes; access to interdisciplinary care teams is required to meet complex care needs; ongoing prevention services are needed to reduce or delay disability and decline; and financial incentives must be aligned to support integration of acute and long-term care.

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