8 Topics
5 Days
Programme Overview
Training Description
Chronic Disease Management (CDM) training is essential for multidisciplinary teams working across primary care, outpatient clinics, and community health settings to manage long-term health conditions effectively:
- Primary Care Clinicians: General practitioners, family physicians, nurse practitioners, and physician assistants who lead ongoing patient care plans.
- Nursing & Clinical Support Staff: Registered nurses, chronic disease care coordinators, medical assistants, and home health nurses.
- Allied Health Professionals: Clinical pharmacists, registered dietitians/nutritionists, physical therapists, and occupational therapists.
- Behavioral Health & Social Support: Medical social workers, health coaches, counselors, and community health workers.
- Healthcare Administration & Quality Teams: Clinic managers, quality improvement coordinators, and population health analysts managing patient registries and clinical outcomes.
Session Objectives
- Define the epidemiological burden and core principles of chronic disease management versus acute care models.
- Apply the Chronic Care Model (CCM) to optimize health system design, clinical decision support, and self-management support.
- Execute structured, evidence-based care protocols for major chronic conditions, including diabetes, hypertension, heart failure, and chronic obstructive pulmonary disease (COPD).
- Engage patients as active partners using motivational interviewing, goal setting, and personalized action plans.
- Utilize population health tools, patient registries, and risk stratification to identify high-risk individuals and track clinical outcomes.
About the Course
Welcome to the training on Chronic Disease Management (CDM).
Chronic conditions—such as diabetes, cardiovascular disease, chronic respiratory illnesses, and chronic kidney disease—represent the leading cause of death, disability, and healthcare expenditure globally. Unlike acute trauma or sudden infections, chronic illnesses are long-term conditions that rarely have a simple cure. They require continuous, lifelong collaboration between patients and healthcare teams.
Traditional healthcare systems were built primarily for acute care: finding a problem, fixing it quickly, and discharging the patient. Chronic disease management requires an entirely different paradigm. It shifts the focus from reactive treatment to proactive, coordinated, patient-centered support that emphasizes prevention, lifestyle modification, early monitoring, and sustained self-care.
Why This Training Matters
Without structured management, chronic diseases frequently lead to acute medical emergencies, repeated hospitalizations, and a severe decline in patient quality of life. Empowering healthcare teams with chronic disease management strategies transforms patient trajectories—preventing complications, reducing system strain, and helping individuals live full, independent lives despite their diagnoses.
By the end of this program, participants will possess the clinical frameworks, behavioral communication tools, and population health strategies needed to excel in chronic care delivery.
Curriculum & Topics
8 Topics | 5 Days
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Subtopic 1.1:
Overview of the global chronic disease epidemic and its socioeconomic impact.
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Subtopic 1.2:
The Chronic Care Model (CCM): Integrating health system design, delivery system design, decision support, clinical information systems, self-management support, and community resources.
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Subtopic 1.3:
Shifting from episodic acute care to continuous, proactive population health management.
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Subtopic 2.1:
Utilizing electronic health record (EHR) registries to track cohorts of patients with chronic illnesses.
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Subtopic 2.2:
Risk stratification models to identify high-risk, high-utilizer patients requiring intensive care coordination.
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Subtopic 2.3:
Utilizing clinical quality measures (e.g., HEDIS metrics) to drive performance improvement.
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Subtopic 3.1:
Comprehensive care protocols for Type 1 and Type 2 diabetes.
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Subtopic 3.2:
Monitoring glycemic control (HbA1c targets, continuous glucose monitoring).
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Subtopic 3.3:
Prevention, screening, and management of chronic diabetic complications (nephropathy, neuropathy, retinopathy, and diabetic foot ulcers).
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Subtopic 4.1:
Evidence-based guidelines for blood pressure measurement, management, and resistant hypertension.
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Subtopic 4.2:
Chronic heart failure (HF) self-management: daily weight tracking, fluid restrictions, medication adherence (ACE inhibitors, beta-blockers), and recognizing early signs of decompensation.
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Subtopic 4.3:
Lipid management and cardiovascular risk reduction strategies.
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Subtopic 5.1:
Differentiating and managing Chronic Obstructive Pulmonary Disease (COPD) and Asthma.
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Subtopic 5.2:
Proper inhaler technique education and pulmonary rehabilitation referrals.
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Subtopic 5.3:
Action plans for managing acute exacerbations and preventing hospital readmissions.
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Subtopic 6.1:
The philosophy of patient self-management: shifting from telling patients what to do to partnering with them.
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Subtopic 6.2:
Motivational Interviewing (MI) techniques to address patient ambivalence regarding lifestyle changes (diet, exercise, smoking cessation).
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Subtopic 6.3:
Collaboratively building SMART (Specific, Measurable, Achievable, Relevant, Time-bound) action plans.
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Subtopic 7.1:
Identifying how social factors—housing stability, food security, transportation, financial strain, and health literacy—impact chronic disease control.
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Subtopic 7.2:
Screening tools for SDOH in clinical workflows.
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Subtopic 7.3:
Connecting patients with community-based resources, social work, and support networks.
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Subtopic 8.1:
The role of multidisciplinary teams (care coordinators, pharmacists, dietitians) in managing complex chronic patients.
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Subtopic 8.2:
Seamless transitions of care: post-discharge follow-up, medication reconciliation, and preventing avoidable readmissions.
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Subtopic 8.3:
Leveraging technology: Remote Patient Monitoring (RPM) devices (blood pressure cuffs, glucometers) and telehealth for proactive outpatient tracking.
