Improving chronic disease self-management in high-risk patient populations

Chronic diseases can be prevented, controlled, or modified through healthy behaviors, and these changes have the potential to produce major transformations in the current health care system. Innovative approaches to execute effective transitional care to reduce health care costs, decrease re-hospitalization, and improve quality care. Studies have indicated the use of health coaching as a potential method for improving self-management, with the aim of improving compliance with health behaviors and sustainable lifestyle changes. Post-discharge follow-up using appropriate transitional models can influence the likelihood of patient’s management of care at home and can help determine what re-admission prevention programs can be effective. Gathering information from patient-centered, evidence-based efforts conducted for better self-management of chronic disease and effective transition from hospital to home. Hospitals should consider using a quality improvement infrastructure that incorporates patient perceptions, mental and physical status’, transition coordination, and self-management sessions that are patient-centered for implementation to ultimately reduce the risk of re-hospitalization in patients who suffer from chronic conditions.