Chronic Care

Key takeaways

You can manage chronic conditions more confidently with a simple plan you follow day by day.
Treat the cause when possible, build a care team you trust, and use regular check ins to adjust what is not working.
Movement, nutrition, medicines taken as directed, and staying up to date on vaccines reduce complications.
Self management and goal setting improve quality of life and help you stay independent.

What ongoing chronic care means

Chronic care is the day to day work of protecting your health and preventing flare ups or complications. If you live with conditions such as diabetes, heart disease, COPD, asthma, arthritis, kidney disease, or depression, ongoing management brings the pieces of care together. It includes your home routines, your medicines and monitoring, your preventive care, and your scheduled visits. The goal is to help you feel better, function better, and avoid avoidable hospital or emergency visits.

Build a plan around your conditions

Create a one page care plan that lists your diagnoses, medicines, allergies, key targets like blood pressure or A1C, your goals, and who to call for help. Bring this to every visit. Ask your clinician to review and update it so everyone is on the same page.

Daily self care routines that matter

Use self management skills

Self management programs teach skills to handle symptoms, set realistic goals, and make decisions with your care team. Many people report better quality of life, more confidence, and fewer unplanned visits after learning these skills.

Move most days

Aim for regular movement that fits your abilities such as brisk walking, cycling, swimming, gentle strength training, or tai chi. Even short sessions add up. Strength and balance work help with stability and reduce fall risk.

Eat for steady energy and heart health

Focus on vegetables, fruits, whole grains, beans, nuts, lean proteins, and healthy fats. Limit added sugars, sodium, and refined grains. Choose water often. If you have kidney disease, diabetes, or heart failure, ask for a personalized plan that matches your needs.

Sleep and stress care

Keep a consistent sleep schedule and practice simple stress reducers like paced breathing, brief walks, or a relaxing routine in the evening. Better sleep and lower stress can improve pain, mood, and blood pressure.

Medicines, monitoring, and safety

Take medicines as directed

Keep an up to date medication list with dose and time of day. Use pill organizers, reminders, or pharmacy packaging if needed. Ask at every visit if any medicine can be simplified, lowered, or stopped. A quick review at transitions such as hospital discharge can prevent errors.

Check key numbers at home

Home checks make visits more productive and can improve control. Examples include blood sugar logs for diabetes and home blood pressure for hypertension. Share your readings so your care team can adjust treatment. If you feel dizzy or lightheaded on your current plan, call to review.

Prevent interactions and side effects

Tell your team about all prescription medicines, over the counter products, vitamins, and supplements. Report new symptoms such as swelling, cough, constipation, confusion, or increased sleepiness. Ask how to recognize urgent side effects and when to seek care.

Prevent infections and other complications

Stay current with adult vaccines

Vaccination reduces serious illness from flu, COVID, pneumonia, shingles, and more. Review the adult schedule each year or after major health changes. Ask which vaccines are recommended for your age and conditions.

Prepare action plans for conditions that flare

Written action plans help you know what to do when symptoms change. Examples include an asthma action plan with green, yellow, and red steps, or a COPD plan with early treatment for flare symptoms. Keep a copy at home and share with caregivers.

Reduce fall risk

Falls are a common cause of injury as we age, and many are preventable. Clear clutter, add good lighting, use grab bars where needed, and wear supportive shoes indoors. Ask about balance and strength exercises. Bring up any dizziness or near falls at your next visit.

Mental health and social support

Depression and anxiety are common with long term illness and are treatable. Ask for screening and help if you notice persistent low mood, loss of interest, sleep changes, or hopelessness. Staying socially connected improves health and makes care easier. Consider local groups, community centers, or peer support.

Healthy movement and nutrition at a glance

Move at a moderate effort for at least two and a half hours per week, add muscle strengthening on two days, and do balance work if you are at risk for falls. Choose an eating pattern that fits your culture and preferences while meeting your nutrition needs. Small changes done consistently make the biggest difference.

Smart goal setting that actually works

Pick one priority for the next two to four weeks such as adding a ten minute walk after lunch or checking blood pressure three days each week. Make your goal specific, measurable, and realistic. Write it on your care plan. Review how it went and adjust at your next check in. If a goal does not work for you, try a smaller or different step.

When to contact your care team

Call if you have new chest pain, trouble breathing, signs of stroke, severe weakness, fainting, fever with chills, a fall with head injury, or a wound that is not improving. If your symptoms are rapidly worsening or you are unsure, seek emergency care.

How coordinated care helps

Care coordination connects your primary care, specialists, pharmacy, home health, and community services. Many people qualify for Medicare supported chronic care management that provides monthly check ins, help with medicines and appointments, and a shared care plan. This support can reduce emergency visits and help you reach your goals.

Your next steps

Choose one small change to start today. Update your one page care plan. Schedule routine care and ask about vaccines you may need. If you want help coordinating care, transportation, mobility equipment, or medication costs, reach out to an advocate who can organize the steps with you.

FAQ

• What is ongoing chronic care?
  Ongoing chronic care is the daily work of managing long term conditions like diabetes, heart disease, COPD, arthritis, kidney disease, or depression. It includes your home routines, medicines and monitoring, preventive care, and regular visits to help you feel better, function better, and avoid preventable hospital or emergency visits.
• Why does having a simple plan matter?
  A one page plan that lists your conditions, medicines, allergies, key targets like blood pressure or A1C, your goals, and who to call makes care easier. You bring it to every visit so you and your care team stay on the same page and can adjust what is not working.
• What daily self care routines help most?
  Helpful routines include moving most days, eating in a way that supports steady energy and heart health, taking medicines as directed, getting enough sleep, and using stress reduction strategies. Self management programs can teach skills to handle symptoms, set goals, and make decisions with your clinicians.
• How should I move if I have chronic conditions?
  Aim for regular movement that fits your abilities such as walking, cycling, swimming, chair exercises, or tai chi. Work toward at least two and a half hours per week of moderate effort activity, plus strength work on two days and balance practice if you are at risk for falls. Start low and build up slowly.
• What does healthy eating look like for chronic care?
  Most people do well with vegetables, fruits, whole grains, beans, nuts, lean proteins, and healthy fats, while limiting added sugars, sodium, and refined grains. If you have diabetes, kidney disease, or heart failure, ask for a personalized nutrition plan that fits your needs, culture, and budget.
• How can I keep my medicines and monitoring safe and organized?
  Keep an up to date medication list with dose and time of day for each item. Use pill boxes, reminders, or pharmacy packaging if helpful. Bring the list to every visit and ask if anything can be simplified. Track key numbers at home such as blood sugar or blood pressure and share your readings with your care team.
• How do I lower the chance of side effects or interactions?
  Tell your team about all prescriptions, over the counter products, vitamins, and supplements you use. Report new symptoms like swelling, cough, constipation, confusion, or unusual sleepiness. Ask which side effects are urgent and when to call. Never stop a medicine suddenly without checking first unless you are told to.
• Which vaccines are important if I have chronic conditions?
  Adults with chronic conditions should discuss influenza, COVID, pneumonia, shingles, Tdap, and other recommended vaccines with their clinician. Staying current reduces serious infections that can worsen heart, lung, or metabolic problems and can help keep you out of the hospital.
• How can I prevent flare ups of conditions like asthma or COPD?
  Ask for a written action plan that explains your daily medicines, what to do when symptoms increase, and when to seek urgent care. Keep the plan where you can see it and share it with family or caregivers. Early use of rescue medicines and prompt calls can prevent more serious flare ups.
• What can I do at home to reduce fall risk?
  Clear clutter and loose cords, improve lighting, add grab bars in the bathroom if needed, use nonslip mats, and wear supportive shoes indoors. If you feel unsteady or have had near falls, ask about balance and strength exercises and whether a cane or walker would improve safety.
• How does mental health and social support fit into chronic care?
  Depression and anxiety are common and treatable. Ask for screening if you notice low mood, lack of interest, sleep changes, or hopelessness. Staying connected with family, friends, peer groups, or community centers supports both emotional health and physical health.
• How do I set goals that I can actually keep?
  Choose one specific, realistic goal for the next two to four weeks, such as a ten minute walk after lunch three days a week or checking blood pressure on three mornings. Write it on your care plan. At your next check in, review what worked and adjust. Small steps done consistently matter more than big plans you cannot sustain.
• When should I contact my care team or seek urgent care?
  Contact your care team if symptoms slowly worsen, if medicines are hard to manage, or if you are unsure about readings at home. Seek emergency care for new chest pain, trouble breathing, signs of stroke, fainting, severe weakness, high fever with chills, a serious fall with head injury, or wounds that are not improving.
• What is coordinated care and why is it important?
  Coordinated care links your primary care, specialists, pharmacy, home health, and community supports so everyone works from the same plan. Many people with chronic conditions qualify for Medicare supported chronic care management with monthly check ins and help organizing medicines and appointments. This can reduce emergency visits and support your goals.
• What are good next steps I can take today?
  You can start by updating or creating a one page care plan, choosing one small self care goal, scheduling routine follow up visits, and asking about vaccines or screenings you may be due for. If you need extra help with care coordination, transportation, mobility equipment, or medication costs, consider working with an advocate or support service.

References

1. CDC Living with a chronic condition overview and self management education
   https://www.cdc.gov/chronic-disease/living-with/index.html
2. Cochrane review summary of self management interventions for chronic disease
   https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD002990.pub4/full
3. Systematic review on self management interventions and quality of life
   https://pmc.ncbi.nlm.nih.gov/articles/PMC11544912
4. Physical Activity Guidelines for Americans key recommendations
   https://health.gov/sites/default/files/2019-09/Physical_Activity_Guidelines_2nd_edition.pdf
5. ODPHP current guidelines overview
   https://odphp.health.gov/our-work/nutrition-physical-activity/physical-activity-guidelines/current-guidelines
6. Dietary Guidelines for Americans 2020 to 2025
   https://www.dietaryguidelines.gov/resources/2020-2025-dietary-guidelines-online-materials
7. CDC Adult Immunization Schedule 2025
   https://www.cdc.gov/vaccines/hcp/imz-schedules/downloads/adult/adult-combined-schedule.pdf
8. NHLBI Asthma treatment and action plan guidance
   https://www.nhlbi.nih.gov/health/asthma/treatment-action-plan
9. NHLBI printable Asthma Action Plan
   https://www.nhlbi.nih.gov/resources/asthma-action-plan-2020
10. NIDDK managing chronic kidney disease and monitoring targets
    https://www.niddk.nih.gov/health-information/kidney-disease/chronic-kidney-disease-ckd/managing
11. CDC and Million Hearts on self measured blood pressure with clinical support
    https://hdsbpc.cdc.gov/s/article/Self-Measured-Blood-Pressure-Monitoring-With-Clinical-Support hdsbpc.cdc.gov
    https://millionhearts.hhs.gov/tools-protocols/tools/smbp.html
12. AHRQ medication reconciliation primer and MATCH toolkit
    https://psnet.ahrq.gov/primer/medication-reconciliation PSNet
    https://www.ahrq.gov/patient-safety/settings/hospital/match/index.html ahrq.gov
13. USPSTF depression screening recommendation for adults
    https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/screening-depression-suicide-risk-adults
14. CDC benefits of quitting smoking timeline and quit resources
    https://www.cdc.gov/tobacco/about/benefits-of-quitting.html CDC
    https://www.cdc.gov/tobacco/campaign/tips/quit-smoking/index.html CDC
15. NIA falls and falls prevention resources and USPSTF falls prevention recommendation
    https://www.nia.nih.gov/health/falls-and-falls-prevention National Institute on Aging
    https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/falls-prevention-community-dwelling-older-adults-interventions
16. ADA Standards of Care in Diabetes 2025 older adults section
    https://diabetesjournals.org/care/article/48/Supplement_1/S266/157556/13-Older-Adults-Standards-of-Care-in-Diabetes-2025
17. AHRQ Health Literacy Universal Precautions Toolkit and action plan tool
    https://www.ahrq.gov/sites/default/files/publications2/files/health-literacy-universal-precautions-toolkit-3rd-edition.pdf
    https://www.ahrq.gov/health-literacy/improve/precautions/tool15.html
18. AHRQ digital health for improved chronic disease management
    https://digital.ahrq.gov/health-it-improved-chronic-disease-management
19. CMS resources on Chronic Care Management for Medicare
    https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/chroniccaremanagement.pdf
    https://www.cms.gov/files/document/chronic-care-management-factsheet.pdf
    https://www.cms.gov/medicare/payment/fee-schedules/physician/care-management

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.