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Massachusetts Medical Society's Physician Focus

November 2014

Managing Your Chronic Disease


  • Chronic diseases such as asthma, heart disease, arthritis, and diabetes affect about half of all American adults, and two out of three have multiple conditions.

  • Traditional care for these diseases has centered on the physician’s role, but a new model of care is focusing on patient self-management.

  • The Healthy Living Center of Excellence offers programs throughout Massachusetts that help patients with chronic conditions manage their own care.

  • Patients who participate in these programs take better care of themselves, improve their health, and remain independent longer.

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Chronic diseases are the leading causes of death and disability in the United States, and their incidence is likely to increase: the nation’s population of 65-plus-year-olds will reach 53 million in 2020, as the baby boom generation reaches the ages when the prevalence of chronic disease increases.

Traditional care of chronic illnesses has centered on the physician’s role, but a new model is emerging, one in which patients become their own principal caregivers.

Such a model is being implemented by the Healthy Living Center of Excellence, a collaborative program of Elder Services of the Merrimack Valley in Lawrence, Mass. and Hebrew SeniorLife in Boston. Through regional-based efforts with community organizations, health care providers and health plans, government, and foundations, the Center promotes evidence-based programs designed to let adults living with one or more chronic conditions take a more active role in their health care.

Robert Schreiber, M.D., a board-certified internist and geriatrician and a proponent of this new model of care, believes these programs have enormous benefits. “One of the key issues that we see,” says Dr. Schreiber, “is that individuals who have a condition are told what they need to do, but they have to modify their lifestyle significantly to incorporate that change, and they need help in understanding what they need to do on a day-to-day basis to actually implement that change.”

Dr. Schreiber, Medical Director of the Healthy Living Center for Excellence, and his colleague, Jennifer Raymond, J.D., M.B.A., Director of Evidence-Based Programs, joined host B. Dale Magee, M.D. on the November edition of Physician Focus to discuss this new model of care and describe its purpose, goals, and benefits.

With traditional care, many patients with one or more chronic diseases would typically see a physician perhaps four times a year, for 15 to 30 minutes at a time. Those visits, however, may not offer enough time for patients to have their questions answered about the multiple aspects associated with chronic illnesses – areas such as managing pain, nutrition, physical activity, or depression that might accompany the illness.

“Where the traditional model of care has been one that people rely primarily on their physician,” says Ms. Raymond, “you can see where that model doesn't work quite so well when we have someone who has a long-term chronic condition. They need more than 15 minutes at a time to manage it, and that management is happening in the home with their family, with their care group.”

Dr. Schreiber describes the new model as one where “the patient is the captain of his health care ship” and the clinician is there to offer help and guidance when needed.

He notes that at least 30-40 percent of health outcomes are not related to medical issues but rather result from a person’s behavior. Such habits as smoking, drinking, poor diet, and a sedentary lifestyle, for example, have huge impacts on health. An individual’s environment, along with housing conditions –two areas that physicians know affect health but likely have little or no training in – are also critically important.

The Center’s programs are customized to the particular needs of the patient and go beyond the traditional medical care of physical testing and evaluation, taking into account the many factors that influence health to build support systems for the patient.

The programs are conducted in community settings such as YMCA’s, libraries, hospitals, and senior centers and offered through seven regional centers across Massachusetts close to where patients live.They are free and open to any patient over 18 years of age with one or more chronic illnesses.

“The programs are not designed to replace the physician,” Ms. Raymond is quick to point out, but rather to establish a “partnership between the physician and patient.”

The results of the programs have proven their worth, says Dr. Schreiber. Patients completing these programs have had better health outcomes, better care experiences, better communication with their providers, and are much more able to manage their conditions.

“That’s exactly what we all want,” he says, “to live better, live healthier, and be able to live as long as we can independently and that’s what these programs do.”

View the video above for more information, including conversation about the locations of the programs, how the programs use technology, and the effect the programs have on the physician-patient relationship.

Patients and providers may call The Healthy Living Center of Excellence at 1-800-892-0890 for more information or to enroll in any of the programs offered through seven regional centers in Massachusetts.

MMS/Richard Gulla

Healthy Living Center of Excellence

Hebrew SeniorLife

Hebrew SeniorLife Blog

Stanford University School of Medicine Patient Education

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"Managing Your Chronic Disease" PSA

From left, Dale Magee, M.D.; Jennifer Raymond, J.D., M.B.A.; Robert Schreiber, M.D.
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