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Coordination of Care Improves Outcomes for Patients With Multiple Ailments

Study finds improvement when health professionals communicate about treatment of chronic conditions

Doctors at a table discussing a patient's care plan

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For older adults with multiple major health conditions, coordination of care can lead to several better health outcomes, a comprehensive study has determined.

Coordination “with one or a combination of case management, care pathways, self-management and education appear to have the greatest potential for impact,” the study authors wrote in their report, published in the Canadian Medical Association Journal. In particular, they found, older adults who have both diabetes and depression or chronic obstructive pulmonary disease (COPD) or who have both COPD and heart failure can benefit to lower blood glucose levels, “reduce depressive symptoms, improve health-related functional status and increase the use of mental health services.”


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More than 62 percent of Americans age 65 or older have two or more chronic conditions, the study reported, and people in such circumstances “have greater health care needs, are at higher risk for adverse health outcomes and are admitted to hospital more frequently, yet only 55 percent receive appropriate care.”

The study noted the “paucity of interventions” created to target multiple conditions, “particularly for chronic diseases that most frequently occur in clusters,” like depression and diabetes.  Each can be a risk factor for the other, so “self-care and medication adherence are often substantial obstacles to improving outcomes.” Future study is needed for such common multiple conditions, the authors recommended.

Study leader Monika Kastner of the University of Toronto told Reuters that “we need to focus on a more patient-oriented and holistic strategy that targets management of patients with common disease combinations … rather than treating one disease at a time.”

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