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An Interprofessional Approach to Chronic Conditions

Approximately 120 million Americans have one or more chronic illnesses and more than 70-80 percent of health care costs are expended on the care of patients with chronic disease. The increase prevalence of chronic conditions, particularly among the elderly, has led to new models of chronic care management. Management of chronic conditions focus on treating the disease, but also managing its symptoms and improving the function and quality of life of the patients. New practice guidelines continue to evolve in caring for patients with chronic conditions. Collaboration among health professionals is a new approach in caring for patients with chronic conditions---particularly forming a partnership between caregivers and patients. This collaborative model in managing patients with chronic conditions will enable patients to take an active role in their own care.

This series of learning modules will cover an important area of chronic conditions which all health care professionals should focus on in order to improve geriatric care.

Module 1: Effective Interprofessional Teams in Managing Chronic Conditions


Lauren Collins, MD
Leigh Ann Hewston, PT, MEd.
Molly A. Rose, RN, CRNP, PhD
Tarae Waddell-Terry, MS

Christine Arenson, MD, Nancy L. Chernett, MPH, Christine Hsieh, MD,
Ina Li, MD, E. Adel Herge, MS, OTR/L

The Eastern Pennsylvania-Delaware Geriatric Education Center (EPaD GEC) is funded by the Department of Human and Health Services Grant #D31HP08834


"Interprofessional Care is the provision of comprehensive health services to patients by multiple health caregivers who work collaboratively to deliver quality care within and across settings. Interprofessional care can be systemically implemented to assist in health care system renewal and improved sustainability."
(Inter-professional Care: Blueprint for Action (Oandasan & Closson, 2007)

Chronic conditions are "any conditions that require ongoing adjustments by the affected person and interactions with the health care system."
(Improving chronic illness care, 2008)

Conditions such as asthma, diabetes, heart disease, obesity and tobacco are considered to be chronic conditions. Chronic conditions are continuing to increase; therefore developing innovative and impactful methods to deliver quality patient care are essential. It is suggested that: "133 million people, or almost half of all Americans, live with a chronic condition. That number is projected to increase by more than one percent per year by 2030, resulting in an estimated chronically ill population of 171 million."
(Improving chronic illness care, 2008)

Models of care such as the chronic care model and effective teams/interprofessional care models help in improving healthcare services to patients and their caregivers living with chronic conditions.

The concept of this module is to give healthcare professionals and students a framework for developing an interprofessional approach to managing chronic conditions.

Learning Objectives:

Upon completion of this module, the participant will be able to:

  • Review epidemiology of chronic disease and the Chronic Care Model.
  • Provide a background on effective interprofessional teams and collaborative practice.
  • Describe the importance of effective interprofessional teams in chronic care.
  • Apply the interprofessional approach to management of chronic conditions using Congestive Heart Failure as a case study.
Estimated time for completion: 45 minutes

Since this module will take approximately 45 minutes to complete, it is designed to track your progress allowing you to complete the module in more than one sitting. This progress tracking feature required that you use the same computer each time you return to work on the module.

Technical Requirements and Notes:

This learning module uses Adobe Flash media and may require you to add a browser "plug-in" in order to display properly. Most computers already have this free plug-in installed. But, if yours does not, it is very easy to download and install. Try the module first because the software is "smart" enough to detect the Flash player. If the module doesn't begin, you will be automatically prompted to download the plug-in.

The module contains links to external websites which will open in a new browser window. Your browser's back button will not return to the module, so these new windows should be closed.

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