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

• What is chronic care?
  Chronic care is long term, organized support for health conditions that last at least a year and need ongoing medical attention or limit daily activities. It focuses on steady progress, preventing complications, and maintaining quality of life.
• How is chronic care different from urgent or short term care?
  Urgent or short term care treats immediate problems. Chronic care supports you over time with regular follow up, monitoring, and planning so you can live as well as possible with an ongoing condition.
• Who is involved in chronic care?
  Chronic care usually includes your primary care clinician, specialists, nurses, pharmacists, mental health professionals, social workers, and community resources working together as a team.
• What does a good chronic care program include?
  It includes a primary care relationship, a shared care plan, regular follow up, medication review, coordination among specialists, self management support, preventive care and vaccines, help during care transitions, and connections to community resources.
• What is a shared care plan?
  A shared care plan is a living document that lists your diagnoses, medications and allergies, care team, goals, monitoring schedule, warning signs to watch for, and what to do if problems arise. You keep a copy and it is updated at each visit.
• Who can benefit from chronic care?
  People with conditions like diabetes, heart or lung disease, kidney disease, arthritis, neurologic conditions, depression, or cancer benefit, especially if they have more than one ongoing condition. Caregivers also benefit from having a clear plan and contacts.
• What is the Chronic Care Model?
  The Chronic Care Model is a framework many clinics use to organize services. It emphasizes prepared care teams, informed and engaged patients, planned visits, self management support, evidence based care, and effective use of health information tools.
• How does Medicare support chronic care?
  Medicare may offer monthly care management for people with multiple chronic conditions. Services often include creating and updating a care plan, reviewing medicines, coordinating referrals, and helping after hospital stays or during major care transitions.
• What can I do today to improve my chronic care?
  Bring an updated medication list to every visit, keep a simple health journal, learn how to reach your care team between visits, know your red flag symptoms, stay current on screenings and vaccines, and pick one small health goal to work on at a time.
• When should I contact my clinic promptly?
  Call promptly for sudden shortness of breath, chest pain, severe headache, rapid swelling or sudden weight gain, very abnormal readings, new confusion, fainting, weakness on one side, fever that does not improve, or new symptoms after a medication change.
• How can Understood Care support chronic care?
  Understood Care advocates can help coordinate care, schedule and prepare for appointments, communicate with your clinicians, arrange transportation and home care resources, and support applications for financial help so you can focus on your health.

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/‍

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.