Medical School · Year 3 · Family Medicine · includes a quiz and discussion video

Seminar 04: Chronic Disease Management

Year 3: Family Medicine Clerkship

Learning Objectives

By the end of this seminar, students will be able to:

1. Apply the Chronic Care Model to patient management
2. Set patient-centered goals for chronic conditions
3. Monitor chronic diseases with appropriate testing
4. Coordinate care for patients with multiple comorbidities
5. Address medication adherence and self-management
6. Utilize team-based care approaches

Seminar Outline

I. Principles of Chronic Disease Management

Chronic diseases represent the predominant challenge facing modern healthcare systems, with approximately sixty percent of American adults living with at least one chronic condition and forty percent managing two or more. These conditions account for ninety percent of the nation's $4.1 trillion in annual healthcare spending and constitute the leading causes of death. Common chronic diseases managed in primary care include diabetes mellitus, hypertension, cardiovascular disease, chronic obstructive pulmonary disease, and chronic kidney disease. The family physician serves as the cornerstone of chronic disease management, providing longitudinal care that addresses both the medical and psychosocial dimensions of living with ongoing health conditions.

The Chronic Care Model provides the conceptual framework for organizing effective chronic disease care. This model emphasizes six interconnected components: self-management support that educates and empowers patients, decision support systems that incorporate evidence-based guidelines, delivery system design featuring proactive team-based care, clinical information systems including registries and reminder systems, health system organization that prioritizes chronic care, and community resources and policies that support healthy behaviors. When these elements function synergistically, they transform chronic care from reactive acute episodes to proactive comprehensive management that anticipates patient needs and prevents complications.

Chronic disease management differs fundamentally from acute care in its orientation and approach. While acute care operates episodically with clinician-driven decision-making focused on achieving cures, chronic care requires continuous engagement through partnerships between patients and healthcare teams focused on ongoing management rather than cure. Acute care tends to be reactive, addressing problems as they arise, whereas effective chronic care anticipates complications and intervenes proactively. Perhaps most significantly, acute conditions resolve within defined timeframes, while chronic diseases require lifelong commitment to treatment plans that must evolve with changing patient circumstances and disease progression.

The Quadruple Aim articulates the overarching goals of healthcare transformation, providing direction for chronic disease management efforts. These four aims include achieving better health outcomes for populations, improving patient experience and satisfaction with care, reducing per capita healthcare costs, and supporting provider well-being to prevent burnout. Effective chronic disease programs must demonstrate improvement across all four dimensions simultaneously, recognizing that focusing exclusively on any single aim may compromise the others. For example, aggressive cost-cutting measures that increase provider workload may initially reduce expenses but ultimately harm outcomes through provider burnout and turnover.

<image>Panel A: Pie chart showing burden of chronic disease with prevalence statistics and cost distribution. Panel B: Hexagonal diagram of the six Chronic Care Model components with interconnecting arrows. Panel C: Side-by-side comparison table contrasting acute care versus chronic care characteristics. Panel D: Four-quadrant diagram illustrating the Quadruple Aim with examples of each dimension.</image>

II. Patient-Centered Goal Setting

Effective chronic disease management requires goals that emerge from collaborative conversations between patients and clinicians rather than being imposed by medical professionals. SMART goals provide a practical framework for creating actionable objectives: goals should be Specific enough to clearly define the target behavior, Measurable so progress can be tracked objectively, Achievable within the patient's capabilities and circumstances, Relevant to what matters most to the patient, and Time-bound with defined deadlines for achievement. A vague goal like "exercise more" transforms into a SMART goal when articulated as "walk thirty minutes five days per week for the next three months."

The collaborative goal-setting process unfolds through a series of conversational steps. Clinicians begin by exploring what matters most to the patient, understanding their values, priorities, and life circumstances. Assessment of readiness for change helps identify which behaviors the patient feels motivated and confident to address. Discussion of options and trade-offs allows patients to make informed choices about treatment approaches. Agreement on specific goals documents the shared commitment, while follow-up conversations review progress and adjust plans as needed. This process treats patients as active participants in their care rather than passive recipients of medical instructions.

Goal quality significantly impacts treatment success, making the distinction between effective and ineffective goals clinically important. Poor goals tend to be vague, unmeasurable, and disconnected from patient priorities. Better goals specify exact targets with timelines that matter to patients. For instance, "lose weight" becomes "lose ten pounds in three months through reducing portion sizes and walking after dinner." Similarly, "control diabetes" transforms into "achieve hemoglobin A1c below seven percent by my next visit through taking medications as prescribed and limiting carbohydrates to forty-five grams per meal." These specific formulations enable meaningful progress monitoring and create accountability.

Inevitably, situations arise where clinical guidelines and patient preferences diverge, requiring skilled negotiation. Clinicians should first understand the values driving patient preferences, recognizing that decisions often reflect legitimate concerns about quality of life, treatment burden, or past experiences. Providing clear information about benefits and risks allows informed decision-making without coercion. Negotiation may identify middle ground that addresses patient concerns while maintaining reasonable safety standards. Documentation of these discussions protects both parties legally while respecting patient autonomy. Ultimately, competent patients retain the right to make decisions about their own care, even when those decisions differ from medical recommendations.

<image>Panel A: SMART goal framework displayed as five connected boxes with definitions and examples for each element. Panel B: Flowchart showing the six steps of collaborative goal setting with conversation prompts. Panel C: Before-and-after comparison of poor versus better goals for weight loss, exercise, and diabetes. Panel D: Decision tree for managing situations when guidelines and patient goals conflict.</image>

III. Self-Management Support

Self-management represents the patient's active participation in their own chronic disease care, encompassing the daily decisions and behaviors that occur between clinical encounters. The five core components of self-management include problem-solving skills to address barriers as they arise, decision-making abilities to recognize when professional care is needed, effective resource utilization to access appropriate help, partnership development with the healthcare team, and taking action on agreed-upon health behaviors. Patients who develop competence in these areas achieve better outcomes than those who passively wait for clinician direction, making self-management support an essential element of chronic care.

Patient education forms the foundation of self-management support but requires thoughtful adaptation to individual circumstances. Health literacy assessment ensures educational materials match patient comprehension levels, as nearly half of American adults have difficulty understanding health information. The teach-back method confirms understanding by asking patients to explain concepts in their own words. Written materials should target fifth to sixth grade reading levels and incorporate visual aids including pictures, diagrams, and infographics. Breaking information into small manageable chunks prevents overwhelming patients with excessive detail during a single encounter while building knowledge progressively over time.

Action plans translate general health goals into specific behavioral commitments with defined timelines and accountability mechanisms. Effective action plans specify exactly what the patient will do, when and where the behavior will occur, and what barriers might interfere. Confidence assessment using a zero-to-ten scale identifies goals that may be unrealistic; if confidence falls below seven, the plan should be adjusted to increase feasibility. Identifying support persons who can provide encouragement enhances success rates. Follow-up at subsequent visits reviews progress, celebrates achievements, troubleshoots difficulties, and establishes new action plans building on previous accomplishments.

Self-monitoring enables patients to track disease status between clinical encounters, providing data that informs treatment adjustments. Patients with diabetes benefit from blood glucose logs that reveal patterns of hyperglycemia and hypoglycemia correlated with meals, medications, and activities. Home blood pressure monitoring for hypertensive patients supplements office readings and identifies white coat effects. Asthma patients tracking peak flow measurements and symptom diaries recognize early exacerbation signs. Weight monitoring supports obesity treatment and alerts to fluid retention in heart failure patients. Modern digital tools including smartphone applications and connected devices facilitate self-monitoring while enabling automatic data sharing with healthcare teams.

<image>Panel A: Pentagon diagram showing the five components of self-management with patient examples. Panel B: Comparison of standard patient education versus health-literacy-adapted education approaches. Panel C: Action plan template with fields for behavior, timing, confidence rating, barriers, and support. Panel D: Self-monitoring methods matched to chronic conditions with sample tracking tools.</image>

IV. Medication Adherence

Medication non-adherence represents a pervasive challenge in chronic disease management, with approximately fifty percent of patients not taking chronic medications as prescribed. This non-adherence generates between one hundred and three hundred billion dollars in avoidable healthcare costs annually and accounts for numerous preventable hospitalizations. The consequences extend beyond individual patients to population health metrics and quality measures. Understanding the multifactorial nature of non-adherence enables targeted interventions that address specific barriers rather than assuming all patients share the same challenges.

Barriers to medication adherence span patient, medication, condition, and health system categories. Patient-related factors include forgetfulness, health beliefs that medications cause harm, limited health literacy affecting understanding of instructions, and cognitive impairment interfering with complex regimens. Medication-related barriers encompass side effects that diminish quality of life, complexity of multi-drug regimens, high out-of-pocket costs, and inconvenient dosing schedules. Condition-related barriers arise particularly with asymptomatic diseases where patients feel well despite suboptimal control. Health system barriers include limited access to care, poor communication between providers, and pharmacy challenges involving refill timing and generic substitutions.

Assessing adherence requires non-judgmental inquiry that normalizes the difficulty of taking medications consistently. Opening questions that acknowledge common challenges reduce defensive responses: "Many people find it hard to take medications every day. How has it been for you?" Direct questioning combined with pharmacy refill data from claims databases provides complementary information. Pill counts offer objective verification but require office visits. Biomarkers when available, such as hemoglobin A1c trends for diabetes medications, provide indirect evidence of adherence patterns. Multiple assessment methods triangulate to give clinicians the most accurate picture of actual medication-taking behavior.

Improving adherence requires matching interventions to identified barriers. Simplifying regimens by reducing doses, using long-acting formulations, and employing combination pills decreases the burden of medication-taking. Addressing cost barriers through generic alternatives, patient assistance programs, and lower-cost therapeutic substitutions removes financial obstacles. Reminder systems including pill organizers, smartphone alarms, and refill reminder services combat forgetfulness. Motivational interviewing techniques address ambivalence about medications by exploring concerns and aligning treatment with patient values. Team-based support involving pharmacists for medication therapy management and nurses for adherence counseling extends physician capacity.

<image>Panel A: Infographic showing the magnitude of non-adherence problem with statistics on prevalence and costs. Panel B: Four-quadrant diagram categorizing barriers to adherence by patient, medication, condition, and system factors. Panel C: Scripted examples of non-judgmental adherence assessment questions. Panel D: Matched intervention strategies for different adherence barrier categories.</image>

V. Comorbidity and Multimorbidity

Precise terminology distinguishes different patterns of multiple chronic conditions. Comorbidity refers to additional conditions present alongside a primary index condition, such as depression occurring in a patient whose primary diagnosis is diabetes. Multimorbidity describes the coexistence of two or more chronic conditions without prioritizing any single disease as primary. Complexity adds psychosocial factors including limited social support, financial constraints, cognitive limitations, and mental health conditions to the burden of multiple medical diagnoses. These distinctions carry clinical implications, as multimorbid patients require integrated approaches rather than disease-by-disease management.

Managing multimorbid patients presents unique challenges that compound with each additional condition. Clinical guidelines developed for single diseases often conflict when applied to patients with multiple conditions, recommending medications that interact or lifestyle modifications that prove incompatible. Polypharmacy introduces risks of drug-drug interactions, adverse events, and treatment burden that may outweigh individual medication benefits. Limited visit time prevents adequate attention to all conditions, forcing prioritization decisions. Treatment fatigue accumulates as patients manage multiple regimens, appointments, and restrictions. Fragmented care across multiple specialists creates coordination challenges when communication fails.

Effective multimorbidity management requires prioritization based on patient values rather than medical hierarchies. Integrating treatment for multiple conditions identifies synergies where single interventions address multiple diseases, such as weight loss benefiting diabetes, hypertension, and osteoarthritis simultaneously. Simplifying regimens reduces pill burden through combination medications and eliminating marginally beneficial agents. Coordinating care ensures specialists communicate with each other and with the primary care physician who maintains the comprehensive view. Regular medication reviews assess whether all current medications remain indicated given current conditions and prognosis.

Deprescribing systematically discontinues unnecessary medications to reduce polypharmacy burden. The process begins by listing all medications including over-the-counter drugs and supplements that patients often fail to report. Assessment of continued need for each medication considers whether the original indication persists and whether benefits continue to outweigh risks given current circumstances. High-risk medications including anticholinergics, sedatives, and opioids deserve particular scrutiny. Prioritization identifies which medications to stop first based on risk-benefit profiles. Gradual withdrawal prevents rebound effects and discontinuation syndromes. Monitoring detects symptom recurrence that may necessitate restarting specific medications.

<image>Panel A: Venn diagram illustrating the relationship between comorbidity, multimorbidity, and complexity concepts. Panel B: Examples of guideline conflicts arising in patients with multiple conditions. Panel C: Strategies for managing multimorbidity organized by prioritization, integration, and simplification. Panel D: Step-by-step deprescribing process flowchart with decision points.</image>

VI. Team-Based Chronic Care

Effective chronic disease management requires teams with clearly defined roles matched to each member's training and capabilities. Physicians provide overall medical management, make complex diagnostic and treatment decisions, and offer team leadership. Nurse practitioners and physician assistants handle routine follow-up visits and protocol-based management, extending physician capacity. Registered nurse care managers coordinate care across settings, provide patient coaching, and manage transitions. Medical assistants perform pre-visit preparation, obtain vital signs, and help establish visit agendas. Pharmacists contribute medication management, reconciliation, and adherence counseling. Dietitians provide nutritional counseling while social workers address psychosocial needs and connect patients with community resources. Behavioral health specialists integrate mental health care into primary care settings.

Care coordination functions extend the impact of individual patient visits to continuous population management. Transition care ensures patients receive appropriate follow-up after hospitalizations, preventing readmissions through medication reconciliation, early appointments, and home health referrals. Referral management tracks specialist consultations to ensure completed appointments and obtained results that inform ongoing care. Care gap identification uses population data to find patients overdue for recommended services. High-risk patient management provides intensive support for complex patients at greatest risk for adverse outcomes. Communication systems ensure information flows between team members so that care decisions reflect comprehensive patient knowledge.

Panel management shifts from passive waiting for patients to present for care toward proactive population health management. Disease registries maintain lists of all patients with specific conditions, enabling systematic tracking of care quality. Care gap reports identify which patients are overdue for recommended monitoring, screening, or treatment intensification. Outreach programs contact patients who have not scheduled needed appointments or are past due for testing. Risk stratification algorithms identify patients most likely to experience adverse outcomes, enabling targeted intervention before crises develop. Population metrics track quality measures across entire patient panels, revealing improvement opportunities.

Pre-visit planning maximizes encounter efficiency through preparation before patients arrive. Chart review identifies upcoming care needs including overdue services, recent test results requiring discussion, and outstanding care gaps. Standing orders enable medical assistants to initiate routine services including vaccinations, screening labs, and health maintenance without waiting for physician orders. Team huddles brief all members on the day's patients, identifying those with complex needs requiring extra time or specific team member involvement. Visit agenda-setting with patients ensures that both patient and clinician priorities receive attention during limited appointment time.

<image>Panel A: Organizational chart showing team members and their specific roles in chronic disease management. Panel B: Diagram of care coordination functions with information flow arrows. Panel C: Sample panel management report showing care gaps by condition. Panel D: Pre-visit planning checklist with team member responsibilities.</image>

VII. Monitoring and Follow-Up

Visit frequency should match disease stability and treatment intensity. Stable patients who have achieved treatment goals benefit from visits every three to six months that confirm continued control and address preventive care. Patients undergoing treatment adjustments require more frequent monitoring, typically every four to twelve weeks, to assess response and titrate medications. Newly diagnosed patients need closer follow-up initially as they learn self-management skills and establish effective treatment regimens. Complex or unstable patients may require flexible scheduling that responds to changing clinical status rather than fixed intervals.

Monitoring parameters vary by condition but follow evidence-based guidelines specifying testing types and frequencies. Diabetes monitoring includes hemoglobin A1c every three to six months, annual renal function and lipid panels, and regular eye and foot examinations. Hypertension monitoring tracks blood pressure at each visit with periodic assessment of renal function and electrolytes to detect medication effects. Heart failure monitoring emphasizes weight tracking, symptom assessment, and B-type natriuretic peptide when indicated. COPD monitoring includes periodic spirometry, symptom questionnaires, and exacerbation tracking. Hypothyroidism monitoring requires periodic thyroid-stimulating hormone levels to confirm appropriate dosing.

Clinical inertia describes the failure to intensify treatment when patients have not achieved therapeutic goals despite confirmed adherence. This common phenomenon contributes significantly to suboptimal chronic disease outcomes. Intensification decisions should occur when patients are not at goal, adherence has been confirmed as adequate, and current medications are tolerated without prohibitive side effects. Avoiding the "wait and see" approach that delays necessary treatment adjustments requires systematic review of goal attainment at each visit and willingness to modify regimens when indicated rather than hoping for improvement without intervention.

Referral decisions balance primary care management capabilities against specialist expertise. Diagnostic uncertainty may warrant specialist consultation to confirm or refine diagnoses. Treatment-refractory conditions that fail to respond to appropriate primary care management benefit from specialist evaluation of alternative approaches. Procedures requiring specialized equipment or skills necessitate referral to appropriate specialists. Complex combinations of conditions may require multidisciplinary management through specialty clinics. Patient requests for second opinions deserve respectful accommodation, as patient confidence in care plans enhances adherence and outcomes.

<image>Panel A: Timeline showing recommended visit frequency for different disease stability levels. Panel B: Monitoring parameter summary table organized by condition with testing frequencies. Panel C: Clinical inertia illustration showing suboptimal outcomes from delayed treatment intensification. Panel D: Referral decision algorithm with indications for specialist consultation.</image>

VIII. Behavior Change Strategies

The Transtheoretical Model describes five stages through which individuals progress during behavior change, with different intervention strategies appropriate at each stage. During precontemplation, individuals are not considering change and may be unaware of the need; interventions focus on raising awareness about risks and benefits. Contemplation involves considering change but feeling ambivalent; exploration of this ambivalence helps resolve barriers. Preparation describes active planning for imminent change; support for specific action planning increases success. During action, individuals are actively implementing new behaviors; reinforcement and problem-solving maintain momentum. Maintenance involves sustaining changes over time; relapse prevention strategies address triggers and high-risk situations.

Motivational interviewing provides a counseling approach that enhances intrinsic motivation for change by exploring and resolving ambivalence. Four key principles guide motivational interviewing conversations: expressing empathy through reflective listening that conveys understanding without judgment, developing discrepancy between current behavior and personal values or goals, rolling with resistance rather than arguing or confronting directly, and supporting self-efficacy by expressing confidence in the patient's ability to change. This approach recognizes that patients are more likely to act on internally generated motivations than externally imposed directives.

Practical behavior change tips translate motivation into sustainable action. Starting with small achievable steps builds confidence and establishes habits before advancing to larger goals. Linking new behaviors to existing routines creates environmental cues that prompt action, such as checking blood glucose with morning coffee. Making desired behaviors easy through preparation, like packing gym bags the night before, removes barriers that interfere with follow-through. Tracking progress through logs, apps, or journals maintains awareness and accountability. Celebrating wins, even small ones, reinforces continued effort and builds positive associations with healthy behaviors.

Common behavior change targets in chronic disease management include diet, physical activity, tobacco use, alcohol consumption, and sleep habits. Dietary approaches such as the DASH diet, Mediterranean diet, and plate method provide structured frameworks for healthy eating. Physical activity recommendations emphasize starting low and progressing slowly to build sustainable habits. Smoking cessation combines pharmacotherapy including nicotine replacement, bupropion, or varenicline with behavioral support and quit date setting. Alcohol interventions follow the SBIRT framework of screening, brief intervention, and referral to treatment when needed. Sleep hygiene education addresses the habits and environmental factors that influence sleep quality.

<image>Panel A: Stages of change model depicted as a circular progression with intervention strategies at each stage. Panel B: Four principles of motivational interviewing with example phrases for each principle. Panel C: Practical tips for behavior change implementation with patient-friendly examples. Panel D: Common behavior change targets with specific evidence-based approaches for each.</image>

IX. Health Information Technology

Electronic health records provide essential functions that support effective chronic disease management. Problem lists document active and resolved conditions, maintaining the comprehensive diagnostic picture that informs treatment decisions. Medication lists track current prescriptions, enabling reconciliation across providers and identification of drug interactions. Health maintenance modules track preventive care completion, generating reminders for overdue services. Decision support systems provide alerts for drug interactions, dosing errors, and care gaps. Disease registries enable population management by identifying all patients with specific conditions. Quality reporting functions generate metrics that monitor and improve care delivery.

Patient-facing technology extends chronic disease management beyond office visits into daily life. Patient portals enable secure access to test results, appointment scheduling, medication refills, and provider communication. Remote monitoring systems transmit home blood pressure readings, glucose values, and weights directly to electronic records for clinician review. Smartphone applications support self-management through tracking tools, medication reminders, and educational content. Telehealth visits provide access to care without travel burden, particularly valuable for patients with mobility limitations or those in remote locations.

Quality reporting requirements drive measurement and improvement of chronic disease care. Process measures assess whether recommended services were provided, such as the percentage of diabetic patients with hemoglobin A1c measured in the past year. Outcome measures evaluate actual health status, such as the percentage with A1c below nine percent. Patient experience measures capture satisfaction with care delivery through standardized surveys. Utilization measures track emergency department visits and hospitalizations that might be prevented through effective primary care. These metrics inform both internal quality improvement and external accountability to payers and regulators.

Health information technology poses challenges alongside benefits that require ongoing attention. Alert fatigue develops when excessive notifications cause clinicians to dismiss warnings without review, potentially missing important safety signals. Documentation burden contributes to physician burnout and reduces time available for direct patient care. Digital divide inequities arise when patient-facing technologies benefit only those with internet access and digital literacy. Interoperability limitations prevent information sharing across different electronic health record systems, fragmenting care for patients who see providers in multiple health systems.

<image>Panel A: Electronic health record functions supporting chronic disease management organized by category. Panel B: Patient-facing technology ecosystem showing portals, monitors, apps, and telehealth connections. Panel C: Quality measure types with examples for diabetes care. Panel D: Health information technology challenges with mitigation strategies.</image>

X. Special Populations in Chronic Disease

Elderly patients require modified approaches to chronic disease management that account for limited life expectancy, functional priorities, polypharmacy risks, and cognitive changes. Goals of care should align with prognosis, relaxing strict targets for patients with limited life expectancy in favor of symptom control and quality of life. Functional status preservation often matters more to elderly patients than laboratory values, making functional goals appropriate treatment targets. Polypharmacy risks increase with age, making medication review and deprescribing particularly important. Cognitive assessment identifies patients who may need additional support for medication management and self-care activities.

Patients with limited health literacy face barriers to effective self-management that require adapted communication strategies. Prevalence of limited health literacy is common, affecting nearly half of American adults and disproportionately impacting older individuals, those with lower educational attainment, and non-native English speakers. Simplified language using plain terms instead of medical jargon improves comprehension. Teach-back confirmation ensures patients understand instructions before leaving encounters. Visual aids including pictures, diagrams, and videos supplement written materials. Written instructions at fifth to sixth grade reading levels serve the broadest patient population.

Low socioeconomic status creates multiple barriers to chronic disease management requiring targeted interventions. Medication cost barriers may be addressed through generic alternatives, manufacturer assistance programs, or therapeutic substitutions to lower-cost medications. Food insecurity undermines dietary recommendations; referrals to food assistance programs address this fundamental need. Transportation barriers may prevent appointment attendance; telehealth and transportation assistance programs help maintain care continuity. Insurance gaps complicate access to care and medications; enrollment assistance connects eligible patients with available coverage programs.

Mental health comorbidities significantly impact chronic disease outcomes through multiple pathways. Depression worsens self-management, medication adherence, and physiological disease control across chronic conditions. Anxiety may manifest as somatic symptoms mimicking chronic disease exacerbations or interfere with adherence through medication fears. Substance use disorders complicate management and increase adverse outcome risks. The bidirectional relationship between physical and mental health creates reinforcing cycles where chronic disease worsens mental health while mental health conditions impair disease management. Integrated behavioral health models that embed mental health services in primary care settings address these interconnections.

<image>Panel A: Considerations for elderly chronic disease patients organized by life expectancy, function, medications, and cognition. Panel B: Communication adaptations for limited health literacy including plain language, teach-back, and visual aids. Panel C: Socioeconomic barriers to chronic disease management with corresponding interventions. Panel D: Bidirectional model showing interactions between mental health and chronic disease outcomes.</image>

Summary

• The Chronic Care Model encompasses self-management support, decision support, delivery system design, clinical information systems, health system organization, and community resources
• SMART goals are specific, measurable, achievable, relevant, and time-bound, emerging from collaborative patient-clinician conversations
• Self-management support includes problem-solving, decision-making, resource utilization, healthcare partnership, and action on health behaviors
• Medication non-adherence affects fifty percent of patients taking chronic medications; interventions should match identified barriers
• Multimorbidity management requires prioritizing patient goals, avoiding guideline conflicts, and systematic deprescribing of unnecessary medications
• Team-based care involves panel management, pre-visit planning, care coordination, and clearly defined roles for all team members
• Visit frequency should match disease stability: every three to six months when stable, every four to twelve weeks when adjusting treatment
• Clinical inertia describes failure to intensify treatment when not at goal despite confirmed adherence; avoid "wait and see" approaches
• Stages of change include precontemplation, contemplation, preparation, action, and maintenance, each requiring different interventions
• Motivational interviewing principles include expressing empathy, developing discrepancy, rolling with resistance, and supporting self-efficacy

Key Terms

This content is subject to the MIT License. © 2024–2026 Hibbert School of Medicine.

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