What Is Chronic Care

Chronic care at a glance

Chronic care is the long term, organized support you receive when a health condition lasts at least one year and requires ongoing medical attention or limits daily activities. Unlike urgent or short term care, chronic care focuses on steady progress, prevention of complications, and maintaining the best possible quality of life.

This approach brings together your primary care clinician, specialists, nurses, pharmacists, mental health professionals, social workers, and community resources. The goal is to help you understand your condition, follow a plan that fits your life, and get timely help when needs change.

What chronic care includes

A strong chronic care program usually offers the following elements

• A dedicated primary care relationship and regular follow up
• A shared care plan that lists goals, medications, monitoring, and next steps
• Medication review and help with side effects and costs
• Coordination among specialists with clear communication back to you
• Support for self management skills such as symptom tracking and healthy routines
• Preventive care and vaccines to reduce avoidable illness
• Help during care transitions such as a hospital discharge
• Connections to community and social supports when needs affect health
• Access to advice between visits for new questions or early warning signs

Who benefits from chronic care

You may benefit if you live with conditions such as diabetes, heart disease, lung disease, kidney disease, arthritis, neurologic disorders, depression, or cancer. People with two or more ongoing conditions often need extra coordination to keep treatments aligned and to avoid medication conflicts. Caregivers also benefit from guidance and reliable points of contact.

Common models and programs you may hear about

The Chronic Care Model

Many clinics use the Chronic Care Model to organize services. It emphasizes prepared care teams, informed and engaged patients, self management support, planned visits, evidence based guidance, and good use of health information tools. These pieces work together so you are not left to manage a complex condition on your own.

Medicare care management services

If you have Medicare, your clinic may offer monthly care management for people with multiple conditions. Services typically include creating and updating a care plan, checking on medicines, coordinating referrals, and helping you during transitions. There are related options for a single complex condition, for support after a hospitalization, and for social needs that affect health. Ask your clinic which services apply to you.

How a shared care plan works

A care plan is a living document. It summarizes your diagnoses, medications and allergies, care team, goals, monitoring schedule, early warning signs to watch, and what to do if problems arise. You receive a copy, and each visit updates the plan. This gives you and your caregivers a clear roadmap and helps every clinician stay aligned.

Building your care team

Your team may include

• Primary care clinician who leads overall care
• Specialists who manage specific conditions
• Nurses and care coordinators who monitor progress and help with referrals
• Pharmacists who review medication safety and costs
• Mental health professionals who support mood, sleep, and coping
• Social workers or community health workers who connect you to resources
• Rehabilitation therapists who support strength, balance, and function

What you can do today

• Bring an updated medication list to each visit
• Keep a simple health journal for symptoms, blood pressure, blood sugar, weight, or pain
• Ask your clinic how to reach the team between visits
• Learn your red flag symptoms and when to call
• Schedule recommended screenings and vaccines
• Choose one small goal at a time such as a ten minute walk most days or a consistent sleep routine
• Involve a trusted family member or friend with your permission

Signs you should contact your clinic promptly

• Sudden shortness of breath, chest pain, or severe headache
• Rapid swelling, sudden weight gain, or high readings outside your usual range
• New confusion, fainting, or weakness on one side
• Fever that does not improve or any concerning new symptom after a medication change
  If you believe you are experiencing a medical emergency, call your local emergency number.

How Understood Care can support you

If you want help putting the pieces together, an advocate can assist with care coordination, appointments, communication with your clinicians, transportation, home care resources, and applications for financial help. These services make it easier to follow your plan, prepare for visits, and reduce stress so you can focus on your health. See the related resources in the references.

FAQ: Chronic care at a glance

• What is chronic care?
  Chronic care is long term, organized support for health conditions that last at least one year, need ongoing medical attention, or limit daily activities. It focuses on steady progress, preventing complications, and helping you maintain the best possible quality of life, rather than only reacting to crises.
• How is chronic care different from urgent or short term care?
  Urgent or short term care usually focuses on a specific problem, such as an infection or injury, and ends once that problem is treated. Chronic care is ongoing. It looks at the big picture of your health over time, helps you follow a clear plan, and gives you support between visits so issues are caught early.
• Who is involved in chronic care?
  Chronic care brings together your primary care clinician, specialists, nurses, pharmacists, mental health professionals, social workers, rehabilitation therapists, and community resources. They share information and work from a common plan so you are not left to coordinate everything on your own.
• What does a good chronic care program include?
  A strong program usually offers a regular relationship with a primary care clinician, a shared written care plan, routine follow up, medication review, coordination between specialists, support for self management skills, preventive care and vaccines, help during care transitions such as hospital discharge, connections to social and community supports, and a way to get advice between visits when new questions or early warning signs come up.
• Who can benefit from chronic care?
  Chronic care can help if you live with conditions such as diabetes, heart disease, lung disease, kidney disease, arthritis, neurologic disorders, depression, or cancer. People who have two or more ongoing conditions, or who see many different specialists, often benefit the most from extra coordination. Caregivers also benefit from clear plans and reliable points of contact.
• What is the Chronic Care Model that some clinics mention?
  The Chronic Care Model is a framework many clinics use to organize services. It focuses on prepared care teams, informed and engaged patients, support for self management, planned visits, evidence based care, and good use of health information tools. The goal is to create a system where you and your team work together, rather than leaving you to navigate complex care on your own.
• What are Medicare care management services?
  If you have Medicare and multiple chronic conditions, your clinic may offer monthly care management. This often includes creating and updating a care plan, checking on medicines, coordinating referrals, and supporting you during transitions such as hospital to home. There are related services for people with a single complex condition, after a hospital stay, or when social needs like food, housing, or transportation are affecting health. Your clinic can tell you which services fit your situation.
• What is a shared care plan and how does it help me?
  A shared care plan is a living document that summarizes your diagnoses, medications and allergies, care team, personal goals, monitoring schedule, early warning signs, and what to do if problems arise. You receive a copy, and it is updated at each visit. This gives you and your caregivers a clear roadmap and helps every clinician stay on the same page.
• Who might be on my chronic care team?
  Your team may include a primary care clinician who leads overall care, specialists who manage specific conditions, nurses and care coordinators who monitor progress and help with referrals, pharmacists who review medication safety and costs, mental health professionals who support mood, sleep, and coping, social workers or community health workers who connect you to resources, and rehabilitation therapists who help with strength, balance, and daily function.
• What can I do today to support my chronic care?
  You can bring an updated medication list to each visit, keep a simple health journal for symptoms or key numbers like blood pressure, blood sugar, weight, or pain, ask your clinic how to reach the team between visits, learn your red flag symptoms and when to call, schedule recommended screenings and vaccines, choose one small health goal at a time, and involve a trusted family member or friend if you are comfortable.
• When should I contact my clinic promptly?
  Reach out quickly if you have sudden shortness of breath, chest pain, or a severe headache, rapid swelling, sudden weight gain, or very high readings outside your usual range, new confusion, fainting, or weakness on one side, fever that does not improve, or any concerning new symptom after a medication change. If you believe you are experiencing a medical emergency, call your local emergency number.
• How can Understood Care support my chronic care needs?
  Understood Care advocates can help you put the pieces together. They can assist with care coordination, appointments, communication with your clinicians, transportation, home care resources, and applications for financial help. This support makes it easier to follow your plan, prepare for visits, and reduce stress so you can focus more on your health and daily life.

References

• Centers for Disease Control and Prevention. About Chronic Diseases. Updated October 4, 2024. https://www.cdc.gov/chronic-disease/about/index.html
• Centers for Disease Control and Prevention. Living with a Chronic Condition. Updated May 15, 2024. https://www.cdc.gov/chronic-disease/living-with/index.html
• Centers for Disease Control and Prevention. Fast Facts. Updated July 12, 2024. https://www.cdc.gov/chronic-disease/data-research/facts-stats/index.html
• Agency for Healthcare Research and Quality. Integrating Chronic Care and Business Strategies in the Safety Net Toolkit. https://www.ahrq.gov/ncepcr/care/chronic-tool/index.html
• Agency for Healthcare Research and Quality. Prevention and Chronic Care. https://www.ahrq.gov/prevention/chronic-care/index.html
• Centers for Medicare and Medicaid Services. Chronic Care Management Services MLN Booklet MLN909188. Updated June 2025. https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf
• National Library of Medicine MedlinePlus. Living with a chronic illness reaching out to others. Reviewed September 4, 2024. https://www.nlm.nih.gov/medlineplus/ency/patientinstructions/000602.htm
• Cleveland Clinic. Chronic Care Clinics overview and services. https://my.clevelandclinic.org/departments/chronic-care
• Coleman K, Austin BT, Brach C, Wagner EH. Evidence on the Chronic Care Model in the new millennium. Health Affairs. 2009. Open access summary on PubMed Central. https://pmc.ncbi.nlm.nih.gov/articles/PMC5091929/
• Wagner EH. Improving chronic illness care translating evidence into action. Health Affairs. 2001. Abstract on PubMed. https://pubmed.ncbi.nlm.nih.gov/11816692/

Related Understood Care pages

• Understood Care Chronic Care. https://understoodcare.com/care-types/chronic-care
• Understood Care Care Coordination. https://understoodcare.com/care-types/care-coordination
• Understood Care Appointments. https://understoodcare.com/care-types/appointments
• Understood Care Communication. https://understoodcare.com/care-types/communication
• Understood Care Home Care. https://understoodcare.com/care-types/home-care
• Understood Care Application Help. https://understoodcare.com/care-types/application-help
• Understood Care Transportation Help. https://understoodcare.com/care-types/transportation-help
• Understood Care Social Support. https://understoodcare.com/care-types/social-support

This content is for education only and does not replace professional medical advice. If you have new weakness, severe pain, fever with confusion, chest pain, or trouble breathing, call emergency services.