Chronic and Complex Care Management
Chronic care management applies to ongoing conditions (diabetes, heart failure, COPD, CKD) and complex care to patients with multiple chronic conditions, functional limitations, and high utilization. Know the Chronic Care Model elements: health system, delivery system design, decision support, clinical information systems, self-management support, and community resources. Understand self-management support (goal setting, action plans, problem-solving) versus patient education (knowledge transfer) - knowledge alone rarely changes behavior.
Know care planning with measurable, patient-centered goals; polypharmacy review and deprescribing; risk stratification to target resources; and team-based care with clear role delineation. Recognize the value of care conferences, advance care planning, and palliative care integration for serious illness (symptom relief alongside curative treatment, not only at end of life).
Traps: confusing palliative care with hospice (hospice requires a prognosis of months and foregone curative intent); assuming more intensive management always helps (avoid over-treatment and goal-concordant care failures); focusing on a single disease in a multimorbid patient; and overlooking caregiver capacity. Another trap is measuring success only by clinical metrics while ignoring function and quality of life.
Rule of thumb: In complex care, the plan should reflect the patient's goals and function, address the whole person, and be feasible for the patient and caregiver - not just clinically optimal on paper.
Worked example: An older adult with heart failure, CKD, and frailty has 12 medications. The CM facilitates a review to identify potentially inappropriate medications, aligns with the patient's goal of comfort and independence, and coordinates deprescribing with the prescriber and pharmacist.