In the 21st century, chronic non-communicable diseases are the main cause of morbidity, functional impairment and impaired quality of life and compromise longevity. They impose a heavy burden on families and on the healthcare system.

The traditional approach, whereby the primary practitioner cared for patients with chronic diseases almost by himself, within the community, has in many cases been found to be clinically and economically inefficient.

Since 2007, the Gertner Institute has been leading several breakthrough projects in the management of chromic diseases in the community, together with two of the four Sick-funds in Israel ("Clalit" and "Maccabi") and the Sheba Medical Center.

The initiative includes disease management programs, providing comprehensive care for patients with selected chronic diseases, such as heart failure and chronic obstructive lung disease.

The core personnel in these programs are nurses who have been specially trained to treat these diseases, working in collaboration with specialists (cardiologists and pulmonologists) and primary practitioners in the community, as well as other healthcare professionals, e.g. dietitians, physiotherapists, social workers and clinical pharmacists. The nurses who serve as case managers guide the patients and their relatives in self-care; they coordinate delivery of care with other healthcare professionals in the community; they promote and monitor adherence to treatment regime, and provide immediate response in cases of acute exacerbation in the medical condition. In some of these programs, the disease management is carried out through a call center, and some programs involve tele-monitoring of blood pressure, pulse, heart rate, oxygen saturation and other parameters.

Each of these programs is evaluated in a randomized controlled trial, coordinated by the Unit of Cardiovascular Epidemiology, in collaboration with the Information and Computer and Biostatistics Units of the Gertner Institute.

MOMA 

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