Future directions in chronic illness care

Abstract

People are living longer with diseases, and the integration of care across multiple diseases will become more complex. Chronic care delivery will evolve toward goal-directed care, underscoring the growing need for clear and ongoing communication about patient values and goals, contributing to more nuanced decision-making. To facilitate a higher order of chronic illness care, cognitively based specialties - particularly primary care - will need to have usable, clear decision support that integrates both treatment and illness consequences across multiple morbidities. The sites of chronic illness care will move outside of the medical exam room, and reimbursement will no longer be transaction based. To help patients negotiate the complexity of health-care delivery and behavior change, integrated health-care systems will need to promote access to care and involve community-based organizations as part of the therapeutic landscape.