QURE Polychronic Patient Management

Course #Q2007-

3

Study Points

  1. Improve documentation of new and coexisting conditions, including risk factors that affect the health status of patients with multiple chronic conditions (e.g., advanced illness, issues with medication management, social determinants of health, mental health, and/or frailty).
  2. Increase adherence to guideline-based medication management for common chronic diseases to improve outcomes and reduce hospitalization risk. Examples include heart failure (guideline-direct medical therapy and diuresis), diabetes (integration of new medications to reduce diabetic complications and microvascular risk), and COPD (symptom- and risk-based strategies based on GOLD ABE classification).
  3. Discourage the use of medications with limited evidence of efficacy or known harms to avoid unnecessary polypharmacy and reduce adverse events.
  4. Recommend comprehensive and personalized non-pharmacologic management and connect patients to support services customized to their needs and social determinants of health. Based on program availability, support services may include home health, care management, behavioral health, or palliative or hospice care.