CHRONIC CARE
Chronic care is care over years.
For families managing long-term conditions like diabetes, hypertension, autoimmune diseases and complex multisystem disorders, our team helps coordinate continuous care across specialists, treatments and life events.
What is chronic care?
Chronic care refers to the ongoing management of long-term medical conditions that require continuous monitoring, treatment and support. Unlike acute conditions that are resolved with a single intervention, chronic conditions persist for months or years and often require adjustments in treatment over time.
Common examples include:
- Diabetes (Type 1 and Type 2)
- Hypertension (high blood pressure)
- Autoimmune conditions (like lupus, rheumatoid arthritis)
- Chronic kidney disease
- Neurological diseases (like multiple sclerosis)
- Complex multisystem conditions
Why coordinated care matters
Managing a chronic condition involves multiple aspects of care:
- Regular monitoring of symptoms and biomarkers
- Adjustment of medications based on response and side effects
- Coordination between primary care, specialists and other healthcare providers
- Management of complications and comorbidities
- Rehabilitation and functional support
- Psychological and emotional support
- Education and self-management training
Without coordination, patients may experience fragmented care, duplicate testing, medication errors, and gaps in treatment. ACCORD Asha helps ensure continuity and consistency across all aspects of care. Learn about our approach to rehabilitation and family support.
Longitudinal records and monitoring
Effective chronic care requires keeping track of your health journey over time:
- Comprehensive medical history and treatment timeline
- Regular tracking of vital signs and lab results
- Medication logs and adherence records
- Documentation of symptoms, triggers and responses
- Progress notes from specialist consultations
- Imaging and diagnostic test results
We help families maintain organized records and understand how to interpret their health data over time.
Multidisciplinary coordination
Chronic conditions often require input from multiple specialists, much like rare disease care. Our team coordinates with:
- Primary care physicians
- Specialists (endocrinologists, cardiologists, neurologists, etc.)
- Pharmacists
- Physiotherapists and occupational therapists
- Dietitians and nutritionists
- Psychologists and mental health professionals
- Rehabilitation specialists
Our team helps coordinate appointments, share information appropriately, and ensure that all providers are working toward common goals for your care.
Medication review and management
Many people with chronic conditions take multiple medications:
- Tracking all prescribed medications and dosages
- Monitoring for side effects and interactions
- Reviewing medication effectiveness regularly
- Identifying unnecessary or redundant medications
- Coordinating medication changes with all relevant providers
- Supporting adherence strategies
We work with you and your healthcare providers to ensure your medication regimen is appropriate, effective, and safe. See also our guide for referring doctors.
Rehabilitation and functional support
Chronic conditions can impact daily functioning:
- Physiotherapy for mobility and strength
- Occupational therapy for daily living skills
- Speech and swallowing support
- Respiratory rehabilitation
- Assistive device guidance
- Home modification recommendations
- Caregiver training
- Psychological support
ACCORD coordinates these services to help maintain independence and quality of life.
Family and caregiver support
Living with a chronic condition affects the entire family:
- Emotional and psychological impact on all members
- Financial strain from medical costs and lost income
- Challenges in daily routines and family life
- Impact on education and employment
- Need for long-term planning and support
We provide resources and support to help families navigate these challenges. See our caregiver support and financial support guides, and our comprehensive patients and families guide.
Referrals and transitions
When care needs change or new specialists are required:
- Helping identify appropriate specialists and facilities
- Preparing comprehensive referral letters and documentation
- Coordinating timing and scheduling of appointments
- Ensuring smooth transitions between different levels of care
- Sharing relevant medical history and test results
We make sure no important information is lost during transitions in care. Clinicians can use our referral pathway, and families seeking another perspective can request a second opinion.
Quality of life considerations
Chronic care isn't just about managing symptoms - it's about maintaining well-being:
- Addressing fatigue and energy management
- Supporting social connections and community participation
- Encouraging meaningful activities and hobbies
- Planning for future needs and milestones
- Addressing sexual and reproductive health concerns
- Supporting spiritual and personal growth
We work with you to identify what matters most in your life and help you maintain those priorities despite your health condition.
FAQs
The frequency of specialist visits depends on your specific condition, treatment plan, and how well you're responding to treatment. For stable conditions, visits might be every 3-6 months. For more complex or unstable conditions, visits may be needed more frequently. Our team can help you understand what's appropriate for your situation and coordinate appointments accordingly.
Yes, we can help with medication management. We work with you and your healthcare providers to review all medications, monitor for side effects, check for potential interactions, and ensure you're taking them correctly. We also help identify if any medications are no longer needed or if adjustments are necessary based on your current condition and treatment goals.
We recommend maintaining a personal health journal or using a digital health app to track key information like symptoms, medication schedules, lab results, and appointments. We can help you create a simple system that works for your lifestyle. The goal is to have a clear record of your health journey that you and your healthcare providers can refer to when making decisions about your care.
Yes, several government and charitable programmes may provide assistance:
- Pradhan Mantri Jan Arogya Yojana (PMJAY)
- National Health Mission (NHM) schemes
- State-specific health insurance schemes
- Disability benefits and pensions
- Special education funding
- Non-governmental organisation (NGO) support programmes
Our team can help identify and apply for relevant programmes based on your specific situation.
Medical review
Medical reviewer: To be confirmed before publication — no medical content on this page may go live without human medical review.
Review date: Pending | Next review: Pending
Sources: Content on this page must be verified against Ministry of Health and Family Welfare, ICMR, Department of Health Research, recognised Centres of Excellence, WHO or Orphanet guidance before publication.
Information on this page is for education and care navigation and does not replace consultation with a qualified healthcare professional.
Get help with care
ACCORD Asha
13, Gaushala Rd, Ansal Villas
Satbari
New Delhi 110074
India
Medical emergency warning: ACCORD's website and contact channels are not emergency services. For a medical emergency, contact your nearest emergency department or emergency service.