Chronic Care Management Project


When the disease is not in the acute stage, patients can stay at home rather than in the hospital. This allows them to feel cozier and more comfortable, which can be conducive to recovery. However, at the same time, they must monitor their condition and, if necessary, consult a doctor before a crisis occurs. The main purpose is to develop patient education and monitoring system. Thanks to this, healthcare workers will receive timely information about their health and take action if necessary.


The project is also crucial for the health care system as a whole. First, it is expected to reduce the number of visits by patients with acute illnesses and crises. This will reduce the burden on doctors and allow them to be more successful in treating other patients who need regular or more intensive care. Second, the project involves many nurses who need to check the condition of chronic elderly patients regularly. These health workers will need to be trained to understand customer’s requirements. As a result, the level of education of health workers will increase, which will positively impact the health care system.

Thus, the project should be beneficial for medical practice, increasing the level of medical care and providing older people with a more comfortable life. Thanks to it, older people will understand better what is happening to them and successfully cope with adverse conditions, even without the help of doctors. The methods and results of the project can be used in other fields of medicine among different populations. For example, the results will be helpful for younger people with chronic conditions. Regular monitoring of their diseases will help them better understand how the disease progresses and take the necessary measures.

Background Knowledge of the Problem

The population group targeted by this project is patients over 65 years of age with two or more chronic diseases. Older people are indeed prone to a significant number of chronic and acute diseases; therefore, it is necessary to monitor their condition and help them by all means. At this age, it is more difficult for people to identify deterioration in time. In addition, they constantly feel the influence of their diseases, so they find it challenging to respond to complications. As a consequence, chronic illnesses can worsen too quickly, which is often fatal. This emphasizes the importance and necessity of implementing the project.

Local Knowledge of the Problem

Older people are more likely to develop an illness, mostly due to having more than one chronic disease. Moreover, when each of the existing diseases requires constant drug therapy, the risk of developing adverse effects from the drugs increases significantly. The development and testing of pharmacotherapy regimens worldwide and locally usually does not consider the peculiarities of the effect of drugs on older patients. There is a considerable lack of attention to the elderly age category of patients at the scientific level. This, in turn, leads to the fact that maintaining the quality of life of older and senile persons with a decrease in physical and intellectual capabilities is often overlooked.

Significance of the Problem to Nursing and Healthcare

The most important question is: how will patients aged 65 years and older with two or more chronic diseases feel six months after being asked daily about their condition and educated in the field of medication?

Benefit of the Project to Practice

The PICOT allows presenting the idea as “to improve the wellbeing of the elderly, track the impact of the program on their health, and apply the methods to others.” Understanding this question will help determine the improvement strategy of health care both in the treatment of the elderly and the prevention of chronic diseases at a younger age.


The PICOT is 65 and older people, usually in pension years. The intervention will be provided by online communication services. Compared to similar business types, the main workforce is made of certificated nurses and medicines, while in this project, there will be a student workforce mostly represented. As a result, the student-elder interconnection provides a great communicative and effective process by lowering the costs of visits and transport for customers and nurse’s time and availability.

Scope of the Project

The main purpose is to transmit the mind that due to the growing tendency of “old” nations, curing elderly people is a highly demanded service. With the help of IT, it is possible to increase the number of visits for both a company and customers on the one hand and increase safety, which is crucial nowadays due to the pandemic restrictions. The specific scope of the project is to provide a relatively fresh nursing model in real life: giving online consultations for those who cannot move a lot.

Theoretical Framework

There is a straightforward process, but it does not show the entire magic of the service. When there are no acute symptoms, the patients may stay at home in a more pleasant and familiar environment. However, at any stage, a chronic disease must be monitored closely to avoid the aggravation of the symptoms and prevent early deterioration of the organism. The theory behind the research is that the timely education of the patients and the constant monitoring of their health indicators could improve the patients’ condition and reduce the hospitals’ workload. This approach would require the development of a learning practice for both patients and healthcare workers, which would successfully educate them on the proper monitoring techniques and the use of special health tracking technologies. The concept of the patients’ and healthcare workers’ awareness is central to this study, and it requires an elaborate answer to the question of how to improve and develop this awareness. This provides a clear notion that the theoretical approach of the business is giving the opportunity to develop a strong interconnection between patients and staff by facing older people and young students during education.

Literature Review

Unfortunately, older adults often face various diseases but do not have enough information to cure them correctly and on time. In particular, the interaction of several chronic conditions among the elderly is a topic that is relatively common in the literature. This is because older people are indeed characterized by various diseases, which together can lead to tragic consequences. Thus, the study of this topic and the solution of related issues are necessary. This will alleviate the condition of the elderly and prevent the emergence of crises in time.

Using the Google Scholar search engine, different researches regarding the issue have been found. However, further findings showed a considerable lack of studies regarding the importance of home monitoring of chronic disease symptoms in older patients. The consequences of chronic diseases are widely known, but scientific research mostly avoids delving into deterioration prevention among the elderly. Nevertheless, relatable studies still have been found.

For example, in a study by Raina et al., researchers examined the effects of chronic diseases among people over 65 at the individual and population level. The study showed that chronic disease areas which predicted incident activities of daily living “did not account for the considerable amount of disability at the population level” (Raina et al., 2020). However, at the individual level, these diseases remain serious and cause difficulties in daily functioning. Therefore, it is necessary to help people cope with them.

Other studies confirm the need for assistance to people with different disabilities. Maresova et al. mention the following conditions requiring help: “psychological problems, difficulties in mobility, poor cognitive function, falls and incidents, wounds and injuries, undernutrition, and communication problems” (2019, 1). All of them make it difficult to interact with other people and even maintain one’s own daily life. Regular communication with doctors could significantly improve the condition and mood of the elderly. The authors’ main areas for work include training, technology tools, government support, and systems for communication and mobility. This will help older people feel better and live more comfortably.

Many studies that focus on the hardships of older people can also help young people avoid future health problems. For example, according to a study by Zhao et al. (2018), factors that influence the occurrence of chronic disease include smoking, obesity, alcohol consumption, and even place of residence. People who are exposed to adverse factors are more likely to go through chronic illnesses in the future. Consequently, such projects can help older people maintain a stable state and young people to avoid this need in the future.

Protection of Human Subjects

The current interest in biomedical research’s ethical and legal aspects with human participation, especially with older adults, is due to several reasons. In the field of chronic diseases, biomedical research is extremely important, necessary, and economically demanded. According to the USA laws, patient participation in any clinical research is strictly voluntary. In addition, the patient or his legal representative will be informed in written form about the conditions of the research and the confidentiality of the study. Moreover, they will also be asked to give a writing confirmation that they agree to participate in the project and submit their health-related data for scientific analysis.


This project is for chronic care management based on remote patent monitoring. The primary tool for its implementation is telehealth technologies. In recent years, these technologies have become much more popular and more accessible, which will allow people of any age to use them productively. The project will use two main areas of work with patients. Remote patient monitoring (RPM) will allow daily vitals monitoring to know what is happening with patients. Cerebral cavernous malformation (CCM) is the second area of the project focusing on teaching about diseases and medication and complications to watch for. This will reduce stress patients may feel managing this on their own.

Overview of the Design

The project will be reimbursed by Medicare in the state of Michigan. It aims to work with patients over 65 years old who have two or more chronic conditions. These illnesses include heart failure, diabetes, stroke, cancer, hypertension, depression, renal failure, and others. These diseases are common enough that healthcare professionals have information about their course and treatment; hence, they can provide adequate care for elderly patients who experience these conditions.


First and foremost, it is important to define the portrait of the typical worker in the institution. To begin with, 90% of the whole staff will be nurses with higher education, especially when processing Ph.D. Inclusion criteria are strong communication skills, knowledge of computer programs, working with them, and being willing to help older adults. Exclusion criteria: people with a great amount of intellectual capital, as they must be too highly paid for “not-so-sophisticated” work. The institution remains a medium-size hospital with 30 beds because most clients will be served online, so that there is more need in private rooms for workers than for permanent visitors.


One of the most beneficial ways of working with a patient is providing daily telemedicine consultations. Firstly, patients will ask health care providers about drug reactions, the relationship between disease and condition, and other questions. On the other hand, nurses will call primary doctors for further assessment if needed. Thanks to this, doctors will be able to prevent hospitalization through monitoring and educating. In addition, patients will have to independently use the available instruments to measure blood pressure, pulse, glucose, and other indicators.


The first essential tool is the medical information system, which includes communicating with patients and recording their indicators to track dynamics. More specifically, it implies that both clients and professionals have electronic communication devices, such as computers or smartphones. Other tools are related to patient metrics. These include a thermometer, blood glucose meter, blood pressure meter, and others. With the help of these tools, patients will be able to find out about their condition at any time, even outside the consultation.

Data Collection Procedure

An essential aspect of data collection is the fullest possible patient history. To obtain valuable research results, information about gender, age, lifestyle, diseases, and other elements are needed. This will help to trace the connection between chronic conditions and other vital factors in people’s lives. In particular, it can be an essential aid in the fight against the onset of chronic and acute conditions.

Thus, data collection includes a primary anamnesis and daily monitoring of indicators. The use of the informational system will allow fixing various numbers daily: temperature, blood pressure, glucose level, and others. Then, it will be possible to draw infographics that show the dependence between patients’ conditions, attitudes, and these numbers. In 6 months, these data will become large enough to show the connection between certain phenomena. This will help to adjust the treatment of current patients and interact more effectively with new ones.

Data Analysis

The data helps to understand the significance level of the disease: whether doctors should take urgent measures or not. Besides, the study provides metrics to measure the patients’ confidence, which is a one-sided confidence interval. They will most likely feel better and trust medical workers more. However, most of the data was found using internet databases due to the lack of permission in access to public libraries because of the pandemic situation. The output of the statistical tests related to the dependence of the diseases on age, treatment, and other aspects will help learn how to provide better help to older adults. As a result, the project can become a study of a specific narrow group of the population and provide helpful information for a wider range of patients. This will help improve the health of the population as a whole and the private group. Dependent variables are place and price, while clients, business, and nursing structure are invariable. As a result, the health care system will be less stressed. It enables healthcare professionals to cope with other severe conditions and conduct research to move medicine forward. There were also functional disability tests provided. For instance, Zhao et al. made a test-oriented product demand for older people.


Maresova, P., Javanmardi, E., Barakovic, S. et al. (2019). Consequences of chronic diseases and other limitations associated with old age: A scoping review. BMC Public Health 19, 1431.

Parminder Raina, P., Gilsing, A., Mayhew, A., Sohel, N., Heuvel, E., & Griffith, L. (2020). Individual and population level impact of chronic conditions on functional disability in older adults. PLoS ONE, 15(2): e0229160.

Zhao, C., Wong, L., Zhu, Q., & Yang, H. (2018) Prevalence and correlates of chronic diseases in an elderly population: A community-based survey in Haikou. PLoS ONE 13(6): e0199006.

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