Collaborative Care of a Patient With Multiple,Chronic Physical and Emotional Health Problems

For patients with complex, multisystem chronic illness, traditional models of care that emphasize diagnosis, prescription, and cure are inadequate. The complexities of such conditions require coordinated work with other specialists. The authors argue in this article that providing optimal health care for management of psychosocial and behavioral health concerns of the chronically ill patient calls for a collaborative approach that goes beyond coordination of care. Key elements of extended collaboration include (a) developing and implementing a team approach to patient care, (b) mutual professional socialization and education, (c) open, frequent communication between practitioners and the patient, and (d) establishing appropriate and realistic care goals. Goals must be identified that facilitate effective coping and improve quality of life in the context of chronic, multisystem illness and disability. Achieving treatment objectives should help the patient lead a rewarding life and help both the patient and providers to experience satisfaction with the provider-patient relationship and the collaborators’ individual achievements.