Using good communication skills you may find out from the patients that certain symptoms have either been present for many weeks or ‘on and off’ for a long time.

Sometimes patients will tell you about a chronic problem, such as having ‘blood pressure’. Some patients may use this expression to actually mean ‘headache’. Other patients may have had treatment in the past but stopped either when they felt better or when the medicine was finished.

Firstly, ask more questions to find out what they really mean. Also, if already diagnosed for the chronic condition, find out when and where was this and what treatment was given.

Chronic diseases are those where the patient has to continue follow-up and treatment for many months or years.

With chronic diseases it is important for health workers to establish a system of making booked appointments with the patient for regular follow-up consultations to review the status of a chronic disease.

At such review consultations:

• Determine whether the patient’s condition is improving, stable or deteriorating (ie. better, the same or worse)

• Assess whether patients are taking prescribed treatments properly (ie. the right drugs, in the right doses, at the right time)

• Confirm that patients are following any other management measures which were prescribed like change of diet or lifestyle (eg. stopping smoking, using condoms, etc)

• Use the contact opportunity to further motivate them in managing their condition correctly

• Take appropriate action if the patient’s condition is worse

Many of the important causes of illness and death in adults and adolescents are chronic diseases. In children, apart from malnutrition, chronic diseases are less common.

Common chronic diseases include:

• HIV/AIDS
• Tuberculosis (TB)
• Mental health problems eg. depression and schizophrenia
• Epilepsy
• Hypertension (high blood pressure)
• Diabetes
• Cancers

All these diseases share the need for long-term care which is mostly at home, but with regular planned visits to the health centres and hospitals. Admission to hospital may be required:

• For new cases for assessment and starting of treatment

• If the condition relapses, until patients are well enough to continue with care in the community (by the health centre together with the CHW)

Some chronic diseases like hypertension and some mental illnesses continue for life while others get better with time. For people living with HIV, early diagnosis and treatment of infections can gain many years of active and productive life.

With HIV/AIDS and cancer patients, much suffering, such as from pain, can be relieved with correct management. With TB, though the condition is curable, treatment needs to be taken for many months to ensure complete cure.

The Chronic Care System

Roles in Chronic Care

Hospital/HC4

The doctor/clinical officer will:

1. See referred cases

2. Assess, diagnose and commence treatment

3. Educate/counsel the patient

4. Decide if the problem is complex or not yet stable:

if yes: give a follow up appointment at the hospital

if no: refer to the health centre for continuing care

- record diagnosis and treatment on a patient card and/or bottom part of the discharge letter and send to the health centre with the patient

5. If there is a relapse or other problem: reassess the patient, revise the treatment plan, and send back details on the revised chronic treatment card or referral letter

Health centre

The clinical officer or nurse will:

1. Identify and treat patients with suspected chronic conditions including those with another (acute) illness

2. Give follow-up care:

- ask about side-effects
- check for other problems
- resupply drugs

3. Inform the local Community Health Worker or volunteer who can, if the patient agrees, visit and support the family carer, eg. for persons with HIV/AIDS

4. If there is a relapse or other serious problem: refer the patient back to the hospital for reassessment of the condition and revision of treatment plan

Community health worker/volunteer will:

1. Visit, educate and support patient care by family carers and motivate for adherence to recommended treatment

2. Reinforce education messages on illness & prevention

3. Refer patients to the health centre who have problems with adherence to treatment or who become more ill

4. Link with community groups where relevant, eg. for provision of HIV/AIDS care

Family member/s will:

1. Support and care for the patient in the home

2. Encourage/assist the patient to follow recommended therapy

3. Monitor the patient’s condition and return with the patient to the health centre if this should get worse