Keys to Chronic Disease Interventions

As experts in the medical field continue to learn more about how diseases function within the body, interventions evolve and the nurses on the frontline must adapt the care they give patients.

Radford University's online Registered Nurse (RN) to Bachelor of Science in Nursing (BSN) program teaches students how to conduct research and inform and influence treatment based on their findings. The courses at the heart of this process, like the RN Healthcare Informatics and Technology course and the RN Nursing Research and Evidence Based Practice course, introduce students to the latest chronic disease interventions and research best practices.

What Are Chronic Diseases?

According to the Centers for Disease Control (CDC), chronic diseases are conditions lasting at least one year that require ongoing medical care or limit activities of daily living. Common chronic diseases include heart disease, cancer, stroke and diabetes. The CDC estimates that 60% of U.S. adults have a chronic disease, and 40% have two or more.

Because chronic diseases are the leading cause of death and disability and significant drivers of rising healthcare costs, prevention is a fundamental goal in healthcare. Currently, the CDC recommends a four-prong approach to health promotion and chronic disease prevention, outlined below:

1. Utilizing epidemiology and surveillance systems to track risk factors and disease prevalence
2. Creating communities and environments that make healthy choices more accessible to the public
3. Developing targeted interventions to deliver preventive care earlier
4. Connecting individuals with chronic conditions to clinical services and resources within their communities

What Is the Chronic Care Model?

While chronic disease prevention is critical, nurses must be equipped to intervene with patients with chronic conditions at any stage of their condition. The Chronic Care Model (CCM) provides a framework for healthcare organizations and professionals to improve the quality of care for patients with chronic conditions. According to BMC Primary Care, the model identifies six essential elements for effective complex care delivery, including:

1. Health system organization. This element focuses on the design of healthcare systems and how they function to provide high-quality, comprehensive care. Central to this category are leadership support, effective healthcare teams, clear roles and responsibilities and coordination between primary care and specialty services.
2. Community resources and policies. The availability of community resources can influence health outcomes, so this element emphasizes collaboration among local organizations such as schools, government and nonprofits to ensure patients have access to support services. Additionally, nurses and other healthcare professionals can advocate for policies promoting healthy behaviors and environments.
3. Self-management support. Empowering patients to manage their health is crucial to long-term success. This element involves equipping patients with the knowledge, skills and resources to actively participate in their care. With an emphasis on education, goal setting, action planning and ongoing support, individuals can make informed decisions and adopt healthy behaviors.
4. Delivery system design. Ideally, a care delivery system should promote efficient, proactive and coordinated care. This element includes establishing ways to identify and monitor patients with chronic conditions and conduct proactive outreach, planned visits and care coordination.
5. Decision support. This element provides nurses and other healthcare professionals with evidence-based guidelines and tools for appropriate patient-centered care. Decision support helps clinicians make informed decisions, implement best practices and manage complex cases.
6. Clinical information systems. Nurses can use technology to enhance care delivery and improve communication and decision-making. Clinical information systems may include electronic health records, registries for tracking patients and outcomes and clinical reminders for preventive care and monitoring.

The Role of Nurses in Chronic Disease Management

Nurses assume a critical role in chronic disease management. They are well positioned to practice independently and collaboratively to offer patients more personalized support and resources, according to the National Institutes of Health (NIH). Using tools like the CCM and evidence-based protocols, nurses can take a more active lead in complex care management, particularly in primary care settings. Plus, as noted by the NIH, having nurses involved in chronic care delivery leads to improved outcomes compared to physician-only care.

Chronic disease interventions in nursing use evidence-based resources and protocols to reduce disease burden and improve patient care and outcomes. Graduates of an RN to BSN program, like that from Radford University, will have the necessary, modern skills to apply chronic disease interventions and impact patient health.