Chronic Disease Management 101

A chronic disease is defined as any long-term illness that will have an impact on a patient’s life and health. According to the Centers for Disease Control and Prevention, roughly 117 million people in the United States — about half of adults — suffer from one or more chronic conditions. Chronic diseases account for seven of the top 10 causes of death. While most of these diseases may not necessarily have a cure, they can be treated.

What conditions are considered chronic diseases?

Family Medicine Physician Joseph Rubacky, DO, sees the following long-term illnesses on any given day:

• Coronary artery disease
• Hypertension, also called high blood pressure 
• Hyperlipidemia, or high cholesterol 
• Asthma 
• Chronic obstructive pulmonary disease 
• Depression 
• Anxiety
• HIV
• Inflammatory bowel disease
• Cancer
• Kidney disease 

When it comes to helping patients combat these diseases, Dr. Rubacky says the team at his practice takes the same approach for each patient regardless of the condition — educate, encourage lifestyle modifications, create a medication regime, and monitor the condition.

Educate yourself 

Each patient is educated about the diseases, including what to expect in terms of living with the illness. They’re also informed on what steps they can and should take to maintain control.

Change your lifestyle

With a lot of chronic conditions, lifestyle changes and diet can make a world of difference. Losing weight can significantly improve conditions like high cholesterol, diabetes, and high blood pressure.

Follow a medication regime 

In some cases, patients need medications in addition to lifestyle changes.

Monitor the condition

Physicians schedule follow-up appointments to see if the patient’s condition is improving or getting worse. These appointments can be set every three to six months, or longer if the patient has stabilized. If a patient misses a follow-up appointment or test, they’re notified. There’s also a care manager on staff to work with the most complex patients with chronic diseases.

“Most of our patients with chronic diseases are on more than 10 medications because if they have one chronic disease, they most likely have others, and we have to make sure we’re managing those conditions as a whole,” Dr. Rubacky said. “These patients require special care. Even if they’re seeing multiple specialists for the varying illnesses, we have to look at their care as a whole and make sure that controlling one disease isn’t interfering with another.”

Another part of the process is working with the patient’s family. For one, it’s important to consider all factors of a condition. Sometimes there are environmental or social causes that can be changed. Families can help navigate a patient’s care at home and if a patient is admitted to the hospital. In the past, family physicians saw their patients in the hospital. This isn’t as common anymore, but Dr. Rubacky and his coworkers make this a priority. “Chronic disease management doesn’t stop when a patient is in the office,” he said. “We can’t manage a condition only when it’s convenient. If one of our patients goes to the hospital, we treat them there as well.”

What’s important for patients to keep in mind when it comes to living with a chronic disease is that if they’re willing to fight, their physician will work diligently to help them live the best life they can. “What I try to emphasize with my patients is that I may not be able to cure your disease, but I can help you manage it,” Dr. Rubacky said. “I will work closely with you and, with lifestyle modifications, we can change your health for the better.” 

To find support in a Bayhealth doctor, visit Bayhealth's Find a Doctor page or call 1-866-BAY-DOCS.