Chronic Disease Management Programme

An internist-led chronic disease management programme provides structured, comprehensive care for individuals with long-term health conditions such as diabetes, and cardiovascular diseases. Internists, specialising in adult medicine, take a holistic approach, integrating regular monitoring, medication management, lifestyle counselling, and patient education. This collaborative model aims to prevent complications, minimise hospitalisations, and optimise the overall quality of life.

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Dr Adrian Mondry
Physician (FRG) | MD (HHU Düsseldorf) | MRCP (London) | IM Specialist (ÄKNo) | Hypertensiologist (DHL)

Indications for Chronic Disease Management

Chronic disease management is recommended for individuals who require ongoing care and structured interventions to maintain health and prevent complications. It is particularly suitable for:

  • Newly Diagnosed Chronic Conditions

    Patients recently diagnosed with long-term conditions such as diabetes, hypertension, or hyperlipidaemia benefit from early implementation of a comprehensive care plan to slow disease progression.

  • Complex or Multiple Comorbidities

    Those managing multiple chronic conditions, such as cardiovascular disease combined with diabetes or kidney disease, require integrated care to address overlapping health concerns.

  • Frequent Hospitalisations or Exacerbations

    Patients with recurring hospital admissions or episodes of disease flare-ups benefit from structured management to stabilise their health and reduce the risk of future complications.

  • Ineffective Previous Treatments

    Individuals who have not achieved the desired outcomes with their current treatment plans can benefit from a tailored, multidisciplinary approach to better manage their conditions.

  • High-Risk Populations

    Patients with a strong family history of chronic diseases, lifestyle-related risk factors (e.g., smoking, obesity, or sedentary behaviour), or pre-existing metabolic conditions benefit from proactive monitoring and intervention.

  • Preventive Care Needs

    Those at risk of developing complications from chronic illnesses benefit from regular monitoring, patient education, and early intervention to reduce the likelihood of disease progression.

Benefits of Chronic Disease Management

Effective chronic disease management offers numerous advantages, ensuring comprehensive and patient-centred care:

  • Comprehensive Health Focus

    Managing chronic conditions such as cardiovascular diseases, diabetes, and metabolic disorders reduces complications and improves overall quality of life.

  • Holistic Care Approach

    Emphasising prevention, addressing comorbidities, and supporting mental health fosters well-rounded patient well-being.

  • Continuity of Care

    Ongoing monitoring and personalised treatment plans ensure stability, early detection of changes, and seamless adjustments in care strategies.

  • Coordinated Care Plans

    Collaboration among healthcare providers, specialists, and diagnostic teams ensures a streamlined and integrated approach to managing complex conditions.

Conditions Commonly Managed

Internists specialise in managing a wide spectrum of chronic diseases, tailoring interventions based on the condition’s characteristics and progression.

  • Cardiovascular Health Management: Comprehensive care for hypertension, heart failure, and coronary artery disease, including blood pressure control, cholesterol management, and regular cardiovascular assessments.
  • Diabetes Management: Advanced care for Type 2 diabetes, with a focus on glucose monitoring, HbA1c testing, medication adjustments, and preventive care for complications.
  • Musculoskeletal Health: Management of arthritis, osteoporosis, and chronic pain through bone density monitoring, pain evaluation, and physical therapy.
  • Kidney Disease Care: Monitoring kidney function, managing comorbidities, and slowing progression through dietary counselling and medication adjustments.
  • Metabolic Disorder Management: Addressing conditions such as metabolic syndrome and hyperlipidaemia with tailored weight management, dietary strategies, and medication plans.

Diagnostic Tools and Evaluations

Comprehensive Medical History Review

A thorough assessment of past medical records, lifestyle habits, and family history provides necessary insights into underlying risk factors and guides the development of a tailored care plan.

Systematic Physical Examinations

Detailed evaluations of symptoms, vital signs (e.g., blood pressure, heart rate), and observable physical changes help monitor disease progression and detect early warning signs of complications.

Laboratory Testing

Routine and specialised tests, including blood panels, urinalysis, and biomarker analysis, are used to measure parameters such as blood glucose levels, cholesterol profiles, kidney function, and inflammatory markers. These provide objective data for diagnosing and tracking conditions.

Imaging Techniques

Diagnostic imaging, such as X-rays, CT scans, ultrasounds, and MRI, is utilised to visualise affected organs or structural abnormalities, assess disease progression, and identify potential complications requiring intervention.

Functional and Performance Assessments

Standardised tests to evaluate physical strength, mobility, respiratory capacity, and cognitive function offer valuable insights into how chronic conditions impact daily life. These assessments guide rehabilitation strategies and treatment modifications.

Managing a Chronic Condition?

Consult our accredited specialist for a tailored chronic disease management plan today.

Treatment Approaches

Internists offer a blend of medical treatments, lifestyle strategies, and continuous monitoring to address chronic diseases comprehensively.

Personalised Medication Management

Internists prescribe, review, and adjust medications to effectively control symptoms, slow disease progression, and minimise side effects. Regular reviews ensure treatments remain appropriate as conditions evolve.

Targeted Lifestyle Modifications

Tailored recommendations for physical activity, nutritional planning, and other lifestyle changes empower patients to reduce complications, enhance daily functioning, and improve overall quality of life.

Patient-Centred Education

Internists provide detailed education on self-management techniques, helping patients understand their conditions, recognise symptoms, and adhere to treatment regimens. This proactive approach promotes independence and confidence in managing chronic illnesses.

Collaborative Multidisciplinary Care

Internists coordinate with allied health professionals, including physical therapists, dietitians, and mental health experts, to address the diverse physical, emotional, and nutritional aspects of chronic disease. This team-based approach ensures holistic support tailored to each patient’s needs.

Frequently Asked Questions (FAQ)

How often should I attend appointments?

Appointment frequency varies depending on your condition and its stability. Most patients are seen every three to six months, but some may require more frequent reviews, especially at the onset of disease and while titrating medications. Your internist will create a customised schedule based on your specific health needs.

Can I continue my routine activities?

In most cases, patients can maintain their usual routines. The programme includes tailored strategies to help you manage symptoms effectively while staying active and engaged in daily life.

What happens if my condition worsens?

The programme is designed to respond promptly to changes in your condition. Your internist will adjust your treatment plan as needed, which may include more frequent monitoring or referrals to specialists for additional care.

How can I assess my progress?

Progress is evaluated through regular monitoring of symptoms, blood tests, and other key health markers. These assessments help determine whether your condition is stable or if adjustments to your management plan are necessary.

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Dr Adrian Mondry

Physician (FRG)|MD (HHU Düsseldorf)|Specialist for Internal Medicine (ÄKNo)|Hypertensiologist (DHL)|MRCP (London)

Dr. Mondry has over 30 years of experience as an internal medicine & hypertension specialist.

  • Previously a Senior Consultant in the Department of Medicine at the National University Hospital and Ng Teng Fong General Hospital, where he is currently a visiting consultant.
  • Hypertension Specialist accredited by the German Hypertension League (DHL)

  • Contributed to the latest Singapore ACE Clinical Guidance on “Hypertension – Tailoring the Management Plan to Optimise Blood Pressure Control” as a committee member.

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