Optimal patient care for those with chronic, complex care conditions includes care coordination and patient self-management skills focused on patients’ health knowledge and informed by supportive coaching.
- One out of five Medicare beneficiaries are re-hospitalized within 30 days of discharge from a hospital; three out of four of those readmissions are preventable.
- Physicians report difficulty coordinating care with the following care partners: schools or employers (38%), non-hospitals institutions (31%), social services (19%), other physicians (17%), other health care professionals (13%) and family members (13%).
- Physicians treating patients with chronic conditions believe their training did not adequately prepare them to: coordinate in-home and community-based services (66%), educate patients with chronic conditions (66%), manage psychological and social aspects of chronic care (64%) and manage chronic pain (63%).
- Living with a chronic disease can contribute to chronic stress; stress reduction is essential for the patient’s health knowledge, his/her treatment engagement and retention, and for a favorable treatment outcome.
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