By Dr. Pamela Eisener-Parsche

Managing chronic diseases is a growing part of medical care in Canada. Advances in science, technology and pharmaceuticals mean that many diseases considered fatal just a few decades ago have now become chronic treatable conditions. The elderly, in particular, are now living with one or more chronic diseases for extended periods of time. This new reality requires that many physicians shift the focus of the care they provide towards the management of chronic, incurable illnesses such as heart and kidney disease, diabetes, osteoporosis and Chronic Obstructive Pulmonary Disease (COPD), among others.

The World Health Organization (WHO) reports that 63 per cent of all deaths globally are due to cardiovascular diseases, diabetes, cancers and chronic respiratory illnesses—making chronic disease the leading cause of death worldwide. Patients who are afflicted with chronic diseases often have to manoeuver a complex healthcare system for years at a time. Their care can involve multiple healthcare professionals in different locations, as well as a variety of medications and treatments. In this labyrinthine environment, good communication and a proactive approach to diagnosis and treatment are important.

Positive communication

Focusing on health promotion, disease prevention and early detection is the best strategy for successful chronic disease management. Identification and early treatment of intercurrent illness is particularly important in frail seniors. Equally important is open communication. Transitions in care, particularly in complex chronic cases, are widely viewed as vulnerable points when breakdowns in communication can lead to patient safety incidents.

The Canadian Medical Protective Association (CMPA) advises physicians who are managing a chronic disease to listen actively, show compassion and partner with patients to achieve care goals. After all, patients can play a big part in effectively managing their own chronic disease – whether through medication adherence, physiotherapy or adjusting their lifestyle. Physicians should work with patients to make shared decisions that strike a balance between meeting healthcare goals and providing optimal quality of life.

Documenting discussions with patients, treatment plans and other clinical issues in the medical record is good practice as it can improve continuity of care by communicating to other physicians, nurses and health professionals what took place during a patient meeting and the rationale for a treatment plan. Using structured communication processes and tools, such as handover mnemonics, can help to overcome barriers to effective handovers.

Patient care coordination is enhanced by sharing information appropriately, collaborating with other healthcare professionals, and preparing effective referrals and consultations. Physicians should also have measures in place to help members of their practice know their responsibilities in a chronic disease case. These can include assisting with care coordination, proper information transfer, test result management, and follow-up procedures.

An internal analysis of medical-legal cases that were managed by the CMPA involving chronic diseases showed that communication breakdowns most often occurred during transitions in care. Incomplete verbal or written communications during handovers with other providers were associated with deficiencies in the diagnostic process. For example, in some handovers, poor communication led to delaying or failing to arrange appropriate testing, or failure to communicate the need to follow-up on tests that were ordered.

Among the reviewed CMPA cases involving ineffective communication with patients, more than a third involved people aged 70 and older. This is problematic and highlights the need for clear communication with seniors, who are a growing demographic in Canada, as well as the family members and other caregivers who may be involved in their care.

Documented communication problems often involve a lack of informed consent by a patient for treatment; failure to communicate important and timely information; failure to communicate information clearly in a way that the patient understands; and failure to communicate difficult news about a diagnosis or prognosis. Two-way communication between a physician and patient is key. It is important that patients feel heard by their physicians and other members of their care team. Poor communication can lead to misunderstandings in the doctor-patient relationship.

A patient-centred approach

Taking a patient-centred approach that is respectful of, and responsive to, individual patient preferences, needs and values is advisable. Physicians should inform patients of the prognosis of their illness, how the illness can impact their lifestyle, and suggest solutions for coping with changes to their routine. Patient adherence to treatment plans can sometimes be difficult. Physicians should take steps to educate their patients about the disease they are afflicted with, encourage proper self-care, reinforce key information about the condition, and explore reasons why a patient may be having difficulties with adherence.

It is also important for physicians to recognize the complexity inherent in managing multiple chronic conditions – particularly in seniors. Several different chronic diseases can be present in elderly patients, and balancing these often competing illnesses can be difficult. Certain heart disease medications, for example, can cause blood pressure to drop and lead to falls and fractures that send people into long-term care facilities. Knowing the risks and potential impacts of different treatment regimes, and discussing them with elderly patients and their caregivers, is the right approach. Adult patients, no matter how old, should be involved in the decision making process when it comes to treating multiple chronic diseases.

Physicians should never make assumptions about what treatment plan a patient will choose, but rather should discuss available options. As always, getting the patient to consent to a particular course of treatment is of paramount importance. Doctors should also recognize when a patient, such as a senior, needs help managing a chronic illness. Because patients may be suffering from multiple chronic conditions, careful attention may be required when caring for patients who have chronic illnesses. Again, it may be necessary to watch for interactions among different medications used to treat different conditions.

Chronic disease sufferers also need to know when they should access healthcare services and whom to contact. Physicians and patients should create an action plan and keep it up to date – including symptoms that merit a doctor’s visit, follow-up protocols, a list of required tests, how to manage medications, and information patients should track to assist healthcare providers in monitoring their condition; i.e. blood sugar and blood pressure levels.

Mitigating risks

Caring for patients with chronic diseases can be challenging. However, physicians can take steps to mitigate the risks. These include:

• Educate patients so they can make informed decisions and be engaged in their care.

• Familiarize yourself with relevant clinical practice guidelines provided by specialty societies, recognizing that strict adherence may be difficult to achieve with patients who have multiple chronic conditions.

• Work with patients and other healthcare providers to develop patient-centred care plans.

• Make use of reminders and alerts in electronic medical records to assist in managing follow-up care.

• Implement a process to facilitate timely follow-up. (In addition to a good discussion, written follow-up and discharge instructions are helpful).

• Communicate consistently with patients and other healthcare providers.

• Document patient discussions, treatment decisions and courses of action.

• Have an effective system in place to manage test results and coordinate care. In a collaborative care setting, roles and responsibilities should be clearly defined.

• Evaluate patient outcomes with the patient and their family.

 Managing chronic diseases is likely to be the norm for many physicians going forward. As people live longer, physicians will inevitably have to manage more chronic but treatable conditions. Successful management of chronic diseases can be enhanced by taking a proactive approach to diagnosis and treatment; educating patients about their condition and involving them in their own care; and ensuring good communication with patients, family members and healthcare providers. Seniors especially require open and proactive communications, and physicians need to recognize when the elderly need assistance adhering to a treatment plan.

Dr. Eisener-Parsche is a family physician with a certificate of Added Competence in Care of the Elderly. Her clinical practice in Ottawa has focused on frail seniors for the past 20 years. Dr. Eisener-Parsche is also currently the Director of Physician Consulting Services at the Canadian Medical Protective Association.