Chronic Disease Management Care Plan

Written by: [Your Name]

I. Patient Information

Name: [Patient's Full Name]
Age: 68
Gender: [Patient's Gender]
Diagnosis(es): Hypertension, Type 2 Diabetes, Osteoarthritis
Primary Care Physician: [Name of Patient's Physician]
Emergency Contact: (123) 456-7890 (Spouse)
Insurance Information: XYZ Health Insurance, Policy #123456

II. Introduction

The Chronic Disease Management Care Plan aims to provide a structured approach to managing the patient's chronic condition(s) while promoting their overall well-being and quality of life. This plan is developed collaboratively with the patient, their family members, and the healthcare team.

III. Goals of Care

Manage symptoms effectively to improve daily functioning.
Prevent disease progression and complications.
Enhance the patient's understanding of their condition and self-management skills.
Promote independence and quality of life.
Coordinate care across multidisciplinary teams to ensure comprehensive support.

IV. Assessment

Medical history: History of hypertension, type 2 diabetes, and osteoarthritis. No significant surgeries.
Current medications and adherence: Lisinopril (10mg daily), Metformin (1000mg twice daily), Ibuprofen as needed for pain.
Functional status (physical, cognitive, emotional): Able to perform activities of daily living independently. Reports occasional forgetfulness. No significant mood disturbances.
Social support system: Spouse, children, and close friends provide emotional and practical support.
Environmental factors impacting health: Lives in a single-story house with easy access to transportation.
Mental health screening: No significant findings on mental health screening.
Nutritional status: Balanced diet with occasional indulgences. No significant weight changes.
Barriers to care: Limited mobility due to osteoarthritis.

V. Care Plan

1. Medication Management

Medication	Dosage	Frequency	Purpose
Lisinopril	10mg	Daily	Blood pressure control
Metformin	1000mg	Twice daily	Glycemic control

2. Symptom Management

Develop strategies to alleviate osteoarthritis pain through gentle exercise, hot/cold therapy, and over-the-counter pain relief.
Educate the patient on blood pressure and blood sugar monitoring at home and provide guidance on when to seek medical attention for abnormal readings.

3. Lifestyle Modifications

Encourage regular low-impact exercises such as walking or swimming to improve joint mobility and overall cardiovascular health.
Emphasize the importance of a balanced diet rich in fruits, vegetables, and whole grains to support blood pressure and blood sugar management.

4. Psychosocial Support

Offer information about local support groups for individuals with chronic conditions.
Discuss stress management techniques such as mindfulness and relaxation exercises.

5. Education and Self-Management

Provide education on the importance of medication adherence, regular check-ups, and annual screenings.
Teach self-management skills such as monitoring blood pressure and blood sugar levels and keeping a symptom diary.

6. Care Coordination

Schedule regular follow-up appointments with the primary care physician and specialists as needed.
Facilitate communication between healthcare providers to ensure a cohesive approach to care.

VI. Emergency Preparedness

Develop an emergency action plan outlining steps to take in the event of a hypertensive or hypoglycemic crisis.
Ensure that the patient and their spouse are familiar with emergency contact numbers and procedures.

VII. Advance Care Planning

Discuss preferences for end-of-life care, including resuscitation preferences and advanced directives.
Document preferences in the patient's medical record and provide copies to relevant healthcare providers.

VIII. Evaluation and Monitoring

Conduct quarterly assessments to evaluate medication adherence, symptom management, and overall health status.
Adjust the care plan based on the patient's progress and feedback.

IX. Discharge Planning

Develop a plan for home modifications or assistive devices to improve mobility if osteoarthritis symptoms worsen.
Coordinate with community resources for transportation assistance if needed.

X. Follow-Up

Schedule quarterly follow-up appointments with the primary care physician to monitor progress and adjust the care plan as needed.
Encourage open communication between the patient, their family, and healthcare providers to address any concerns or changes in health status.