Draft · 5 min read

Optimal Care for Chronic Conditions

Stable but serious disability including mental disability

Typical Example

Mr. White, a 56-year-old telemarketer, also is a former paratrooper who is quadriplegic from a gunshot wound to the neck. He lives with his brother in an extensively adapted apartment and has a paid aide for personal care. He has a motorized wheelchair and transportation for shopping and outings. He has been suicidal at various times and often has urinary tract infections. He uses a medical home team for continuity and comprehensive coordination of services, and he and the team work from a negotiated plan of care.

Population (in United States)

7 million



Total Cost/Year

$290 billion

Priority Concerns for this Population

Autonomy, rehabilitation, limiting progression, accommodating environment, caregiver support

Major Components of Health Care

Home-based services, environmental adaptation, rehabilitation, and institutional services

Goals for Health Care

Living with illness or disability

Optimal Care for Serious Disability


Basic cost for health care services, treatments and support services are covered fully. In addition where appropriate lifestyle related interventions, screening and prevention activity are also covered. The cost of acute hospitalization, nursing facility care, long term care, where medically indicated is covered.


The coverage is universal and not dependent on the condition, stage of life or ability to pay. Supplemental insurance may be purchased. Plans may compete of riders for additional services. Employers may also provide additional services. Coverage for education of caregivers will be provided.


Preferably the person who is chronically ill will have a primary care doctor or if indicated a specialist who will coordinate their care. Specialists will be available for consultation in person or through other means to address specific problems. The person will have choice of providers including doctors, hospital, nursing facility, local pharmacy, or certified health club. Emergency Medical Services that can provide immediate care and transfer to appropriate level of care. Home evaluation and treatment available promptly; 24/7 rapid response to home for crises Equal access to health care services tailored to situation. Administrative needs are minimal.

Quality Health Care:

Patient Centered (No Helplessness or Unjustified Routines): Care is patient centric and is provided with dignity, cultural sensitivity and respect for the person. Information is provided in age and education level appropriate manner. Advance care planning consistent with patient’s wishes; resolution of family issues; support of family caregivers. Informed and shared decisions reflecting parents’ values (constrained by legal limits). Lifestyle reflecting informed decisions; self-monitored care; patient and family education.

Safe (No Harm): Care that is provided will be safe from errors. This will be of particular challenge when there are changes in the venue of care. For example the person is in need of hospitalization and the medications they take are not given as ordered.

Effective (No Needless Failures): Specific outcomes will be measures and adjustment in the services made. Recommendations from national agencies and groups will be followed. Care that is effective for the problems experienced by the person suffering with a chronic condition. Evidence-based secondary and primary prevention and rehabilitation. Government and professional association guidelines are readily available and are transparent. Home-based care; nutritional support; reliable facility care when needed; support for caregivers; appropriate preventive services.

Efficient (No Waste): For brief acute episodes, diagnosis is made and care provided in timely efficient manner. A treatment plan is formulated according to an informed dialogue with the person or their legal representatives. Government and professional association guidelines are readily available and are transparent. Regulatory agencies oversee quality of services, and advertising to consumers.

Timely (No Needless Delays): Evaluation and treatment for brief acute episode is available promptly. Convenient and responsive scheduling, no waiting for health care services; immediate access to results of tests; immediate access to clinical guidance and other information; timely education and support; Little waiting for health care services; adequate notice of expected events; convenient and responsive scheduling; immediate access to test results, clinical guidance, and other information; short time to diagnosis and treatment for positive screens and worsening conditions.

Equitable (No Unjustified Variation): Care is provided universally with no bias due to personal characteristics. equal opportunity for important treatments; no bias due to personal characteristics. Regulatory agencies oversee quality of services, and advertising to consumers.

Coordination of Care:

Care is patient centric and revolves around the patient and their doctor (clinician). Care continuum management across multiple providers. Public health services that have provisions for early identification of community trends. Education regarding risk factors and practical ways to avoid them. For identified problem and secondary prevention, care is coordinated regionally, through medical records, supported by privacy provisions. Care in its various levels is coordinated to achieve best outcomes and limit errors and cost. For identified problem and secondary prevention, care is coordinated regionally, through medical records, supported by privacy provisions. Public health provisions for early identification of community trends.


The goal of innovation is to improve quality of the person thorough achieving and maintaining optimal function. Personalized medicine, identified early susceptibility based on genetics, technological tools to assure compliance with treatments and ability to monitor response to interventions. Utilization of personal medical records that can automatically provide reminders of needed screening, immunizations and monitoring response. A personal record of treatments for acute episodes including medications and side effects that is paper or electronic based. It would include new treatments, diagnostic procedures, new services, new monitoring tools new delivery systems and concepts. Updates on research and innovation quickly reaching the point of care and the person who will benefit from it.

  • Monitoring devices for falls, pressure, etc.;
  • Computerized physician order entry with decision support
  • Pain management that is patient specific
  • Electronically available health care plans
  • Advance care plans available
  • Electronically 24/7 access
  • Secure message capability
  • Available in language and level of education of choice
  • Real-time home monitoring devices; e-reminders for screens and monitoring
  • Longitudinal electronic health records and personal health records

Over half of all Americans suffer from chronic illnesses such as cancer, heart disease, diabetes and Alzheimer’s, which now constitute the largest segment of health care in America and cause 7 out of every 10 deaths yearly. These chronic diseases are also costly, with 86 percent of our nation’s total health care spending on those individuals with one or more chronic conditions. Millions of Americans with these conditions are covered by Medicare, and many have more than one condition, which makes treatment even more complex and exponentially more expensive. The Senate Finance Committee is currently crafting bipartisan legislative solutions to improve outcomes and to better coordinate care for Medicare patients with multiple chronic conditions.