Chronic Disease Management Skill

Support longitudinal management of chronic conditions including diabetes, hypertension, heart failure, COPD, and chronic kidney disease. Designed for ongoing care coordination and target-based monitoring.

Overview

This skill enables clinical AI agents to:

• Create condition-specific management protocols
• Track clinical targets and trends
• Manage comorbidities and interactions
• Monitor medication adherence
• Generate annual review checklists
• Support patient self-management

Supported Conditions

Type 2 Diabetes Mellitus

Treatment Targets: | Parameter | Target | Monitoring Frequency | |-----------|--------|---------------------| | HbA1c | <7% (individualize) | Every 3-6 months | | Fasting glucose | 80-130 mg/dL | Daily self-monitoring | | Post-meal glucose | <180 mg/dL | Per patient needs | | Blood pressure | <130/80 mmHg | Every visit | | LDL cholesterol | <100 mg/dL (<70 if ASCVD) | Annual | | eGFR | Monitor trend | Annual | | Urine albumin | <30 mg/g | Annual |

Annual Review Checklist:

• [ ] HbA1c measurement
• [ ] Comprehensive metabolic panel
• [ ] Lipid panel
• [ ] Urine albumin-to-creatinine ratio
• [ ] Dilated eye exam referral
• [ ] Comprehensive foot exam
• [ ] Dental referral
• [ ] Flu vaccine
• [ ] Depression screening (PHQ-9)
• [ ] Self-management review

Medication Considerations:

• Metformin first-line (unless contraindicated)
• Add SGLT2i or GLP-1 RA if ASCVD, heart failure, or CKD
• Insulin if needed for glycemic control
• Statin for all patients 40-75 years
• ACEi/ARB if albuminuria or hypertension

Hypertension

Treatment Targets: | Population | Target BP | |------------|-----------| | General | <130/80 mmHg | | Elderly (>65) | <130 SBP if tolerated | | CKD with proteinuria | <130/80 mmHg | | Diabetes | <130/80 mmHg |

Monitoring Protocol:

• New diagnosis/med change: 2-4 week follow-up
• At target: Every 3-6 months
• Home BP monitoring encouraged

Medication Considerations:

• First-line: ACEi, ARB, CCB, or thiazide
• African American: CCB or thiazide preferred
• Diabetes/CKD: ACEi or ARB preferred
• Heart failure: Specific guideline-directed therapy

Heart Failure

Classification:

• HFrEF: EF ≤40%
• HFmrEF: EF 41-49%
• HFpEF: EF ≥50%

Treatment Targets (HFrEF): | Parameter | Target | |-----------|--------| | Resting HR | 60-70 bpm | | Blood pressure | Per comorbidities | | Daily weight | Stable (±2 lbs) | | Fluid intake | 1.5-2L/day | | Sodium intake | <2g/day |

GDMT for HFrEF:

1. ACEi/ARB/ARNI
2. Beta-blocker (carvedilol, metoprolol succinate, bisoprolol)
3. MRA (spironolactone, eplerenone)
4. SGLT2 inhibitor

Monitoring:

• Stable: Every 3-6 months
• After med change: 1-2 weeks
• Post-hospitalization: 7 days

COPD

Classification (GOLD):

• Group A: Low symptoms, low exacerbation risk
• Group B: High symptoms, low exacerbation risk
• Group E: Exacerbation history (≥2 moderate or ≥1 hospitalization)

Treatment Targets: | Parameter | Goal | |-----------|------| | mMRC dyspnea | <2 | | CAT score | <10 | | Exacerbations | Reduce frequency | | FEV1 decline | Slow progression |

Annual Review Checklist:

• [ ] Spirometry (if diagnostic or declining)
• [ ] Symptom assessment (CAT, mMRC)
• [ ] Exacerbation history review
• [ ] Inhaler technique assessment
• [ ] Smoking cessation counseling
• [ ] Flu vaccine
• [ ] Pneumonia vaccine per schedule
• [ ] Oxygen assessment if needed

Chronic Kidney Disease

Staging: | Stage | eGFR (mL/min/1.73m²) | Action | |-------|---------------------|--------| | G1 | ≥90 (with kidney damage) | Monitor, treat cause | | G2 | 60-89 | Monitor | | G3a | 45-59 | Nephrology referral consider | | G3b | 30-44 | Nephrology referral | | G4 | 15-29 | Prepare for RRT | | G5 | <15 | RRT if appropriate |

Albuminuria Categories:

• A1: <30 mg/g (normal to mildly increased)
• A2: 30-300 mg/g (moderately increased)
• A3: >300 mg/g (severely increased)

Management Priorities:

• Blood pressure control (<130/80)
• Glycemic control if diabetic
• ACEi/ARB if albuminuria
• SGLT2i if proteinuric CKD
• Avoid nephrotoxins
• Adjust medications for GFR

Comorbidity Management

Common Comorbidity Combinations

Diabetes + Hypertension + CKD:

• ACEi or ARB for BP and nephroprotection
• SGLT2 inhibitor if eGFR appropriate
• Target BP <130/80
• Monitor K+ with ACEi/ARB/MRA

Heart Failure + Diabetes:

• SGLT2 inhibitor (proven benefit in both)
• Avoid thiazolidinediones
• Metformin safe unless severe HF

COPD + Heart Failure:

• Cardioselective beta-blocker (bisoprolol, metoprolol)
• Avoid non-selective beta-blockers
• Monitor for volume status

Polypharmacy Considerations

• Review medication list at every visit
• Assess for deprescribing opportunities
• Check drug-drug interactions
• Simplify regimen when possible
• Consider Beers criteria for elderly

Adherence Monitoring

Adherence Assessment

Questions to Ask:

1. "How often do you miss your medications?"
2. "What makes it hard to take your medications?"
3. "Have you stopped any medications because of side effects?"

Red Flags for Non-Adherence:

• Missed refills
• Inconsistent lab values
• Frequent hospitalizations
• Patient expresses concerns about medications

Adherence Interventions

| Barrier | Intervention | |---------|--------------| | Forgetfulness | Pill boxes, reminders, simplify timing | | Side effects | Discuss, consider alternatives | | Cost | Generic options, patient assistance | | Complexity | Reduce number of medications/doses | | Health beliefs | Education, motivational interviewing |

Target Tracking Dashboard

Diabetes Dashboard

DIABETES MANAGEMENT DASHBOARD

Patient: [De-identified ID]
Last Updated: [Date]

GLYCEMIC CONTROL:
┌─────────────────────────────────────────────────┐
│ HbA1c Trend:                                    │
│ Target: <7%                                     │
│                                                 │
│ [Date 1]: 8.5% → [Date 2]: 7.8% → [Date 3]: 7.2%│
│ Status: IMPROVING ↓                             │
└─────────────────────────────────────────────────┘

CARDIOVASCULAR RISK:
• Blood Pressure: 128/78 mmHg ✓ (Target <130/80)
• LDL: 95 mg/dL ✓ (Target <100)
• Statin: Yes ✓

KIDNEY PROTECTION:
• eGFR: 68 mL/min → Stable
• UACR: 45 mg/g → ACEi in place ✓

ANNUAL SCREENINGS:
• Eye exam: Due [Date] ⚠️
• Foot exam: Completed [Date] ✓
• Flu vaccine: Completed ✓

SELF-MANAGEMENT:
• Blood glucose monitoring: Good adherence
• Dietary compliance: Moderate
• Exercise: Below goal

NEXT STEPS:
1. Schedule eye exam
2. Review exercise plan
3. Recheck HbA1c in 3 months

Hypertension Dashboard

HYPERTENSION MANAGEMENT DASHBOARD

Patient: [De-identified ID]
Last Updated: [Date]

BLOOD PRESSURE TREND:
┌─────────────────────────────────────────────────┐
│ Target: <130/80 mmHg                            │
│                                                 │
│ Office: 138/84 → 132/80 → 128/76               │
│ Home Average: 126/78                            │
│ Status: AT TARGET ✓                             │
└─────────────────────────────────────────────────┘

CURRENT MEDICATIONS:
• Lisinopril 20mg daily
• Amlodipine 5mg daily

END-ORGAN ASSESSMENT:
• Creatinine: 1.1 mg/dL - Stable
• Potassium: 4.2 mEq/L - Normal
• ECG: Normal sinus rhythm

LIFESTYLE FACTORS:
• Sodium intake: Moderate
• Exercise: 3x/week
• Weight: Stable
• Alcohol: Social (low risk)

NEXT STEPS:
1. Continue current regimen
2. Follow-up in 6 months
3. Encourage home BP monitoring

Annual Review Templates

Comprehensive Annual Review

ANNUAL CHRONIC DISEASE REVIEW

Patient: [De-identified ID]
Date: [Date]
Conditions: [List active chronic conditions]

OVERALL STATUS: [Stable/Improved/Worsening]

CONDITION REVIEW:

1. [Condition 1]:
   • Current status: [Controlled/Uncontrolled]
   • Target achievement: [Met/Not met]
   • Key metrics: [Values]
   • Changes since last year: [Summary]
   • Plan for next year: [Goals]

2. [Condition 2]:
   [Same format]

MEDICATION REVIEW:
Current medications reconciled: [Yes]
Changes made: [List any changes]
Deprescribing opportunities: [List or None]
Adherence assessment: [Good/Fair/Poor]

SCREENING COMPLETED:
□ [Condition-specific screening 1]
□ [Condition-specific screening 2]
□ Age-appropriate cancer screening
□ Immunizations updated
□ Depression screening
□ Fall risk assessment (if applicable)

LIFESTYLE ASSESSMENT:
• Diet: [Assessment]
• Exercise: [Assessment]
• Tobacco: [Status]
• Alcohol: [Status]
• Sleep: [Assessment]

FUNCTIONAL STATUS:
• ADLs: [Independent/Needs assist]
• IADLs: [Independent/Needs assist]
• Cognition: [Intact/Concerns]
• Falls: [None/History]

GOALS FOR NEXT YEAR:
1. [Patient-centered goal]
2. [Clinical target]
3. [Lifestyle goal]

CARE PLAN UPDATED: [Yes]
PATIENT/CAREGIVER ENGAGED: [Yes]

Follow-up plan: [Frequency and monitoring]

[Provider signature]

Patient Self-Management

Self-Monitoring Protocols

Diabetes:

• Blood glucose: [Frequency based on treatment]
• Log results for review
• Know hypoglycemia symptoms and treatment

Hypertension:

• Home BP: At least 2x/week
• Same time of day, after rest
• Log results

Heart Failure:

• Daily weight (same time, same scale)
• Call if gain >2-3 lbs in 1 day or >5 lbs in 1 week
• Monitor for edema and dyspnea

Warning Signs Education

Condition-specific warning signs when to call:

Diabetes:

• Blood sugar >300 or <70 mg/dL
• Symptoms of high/low sugar not resolving
• Signs of infection

Heart Failure:

• Rapid weight gain
• Increasing shortness of breath
• New or worsening edema
• Unable to sleep flat

Usage Instructions

1. Identify Active Conditions

Document all chronic conditions with:

• Diagnosis and date
• Current severity/stage
• Treatment status
• Target values

2. Create Monitoring Plan

For each condition:

• Define targets
• Set monitoring frequency
• Assign responsibilities
• Schedule reviews

3. Track Progress

Update at each visit:

• Current values vs. targets
• Trends over time
• Adherence assessment
• Barriers identified

4. Conduct Annual Review

Comprehensive yearly assessment:

• All conditions reviewed
• Screenings completed
• Goals updated
• Care plan revised

Integration with TherapyPod

This skill integrates with:

• Treatment Plans - Creates condition-specific plans
• Medication Review - Manages complex medication regimens
• Care Coordination - Coordinates multi-provider care
• ClinEval Benchmark - Clinical accuracy validation

References

• See references/clinical-guidelines-summary.md for guideline sources
• See references/target-values.md for condition-specific targets
• See references/annual-review-checklists.md for screening requirements