Chronic Care - Science and Practice

The importance of a professionally and practically appropriate healthcare system for people with chronic illnesses especially those with multiple chronic conditions is undeniable in light of demographic changes and the increasing number of older adults with limited everyday competence. Although the German Enquete Commission on "Demographic Change" identified requirements and proposed solutions as far back as thirty years ago, there are still significant gaps in both scientific research and practical healthcare provision. This handbook aims to help close these gaps. It brings together various professional perspectives, highlights the interfaces and tools for collaboration among the different professional groups and healthcare institutions involved in care, and presents methods for care planning and development across diverse care settings and arrangements.
Therefore, the handbook is suitable for practitioners involved in direct patient care as well as for those engaged in healthcare planning. At the same time, it is intended for students, researchers, and educators in the field of Chronic Care Sciences and related disciplines, such as medicine, nursing, therapy sciences, social sciences, and social work.

List of contents

I Introduction.- Why a Handbook on Chronic Care?.- What is Chronic Care? Perspectives from science, research, education, and practice.- Transdisciplinarity Chronic Care as a transdisciplinary field.- Chronic Care as a multiprofessional practice field with profession-specific approaches.- II Individual Level: medical aspects, theories of illness, illness experience, coping with illness, practical concepts.- Morphology of chronic diseases.- Prevalence of chronic diseases.- Etiology of chronic diseases.- The masticatory system and chronic diseases.- Multimorbidity and chronic diseases.- Effects of chronic diseases.- Disease trajectories as a shared orientation model for multiprofessional care practice.- Somatic theories of illness and coping.- Sociological perspectives on the social construction of illness and implications for the experience and treatment of illness.- Psychological and psychosomatic approaches to illness.- Human-environment relationships in the context of illness.- Social determinants of health and chronic diseases.- Professional approaches to subjective illness experience.- Salutogenesis, resilience, and coping.- Health literacy.- Setting-specific care: connectivity as a challenge.- Person- and patient-centeredness as care concepts.- Palliative and end-of-life care as care concepts.- Emergency and critical care as care concepts.- Pharmacotherapy, polypharmacy, and adherence.- Technical support systems in individual care.- What if? Social design as a competence expansion in interdisciplinary teams in the context of Chronic Care.- Digital assistance systems for the care of people with chronic illnesses.- III Organizational Level Chronic Care: fundamental aspects, institutional forms of care, and self-determined living.- Migration and Chronic Care.- Transculturality, cultural appropriateness, cultural sensitivity, cultural competence in health care.- Structured care: prevention cure rehabilitation long-term care.- Interfaces and transitions in the care of people with chronic illnesses.- Human resource development and staffing needs considering chronic care.- Interprofessional action and competencies for interprofessional collaboration.- Knowledge management in multiprofessional care processes.- Setting-specific process planning and organizational development.- Concepts of digitalization from the organizational perspective.- Normality and equality in self-determined living with chronic illness.- Chronic illness a family matter.- Self-determined living at home: diversity of living arrangements.- Household-related services for self-determined living.- IV System Level Chronic Care: framework conditions, health care economics, community and public health care, digital health as a societal innovation.- Basics of social law in health care.- Legal guardianship under the guardianship law.- Organizational forms of the health system.- Health policy concepts for the care of people with chronic illnesses.- Introduction to health care economics.- Principles of business administration in facilities for chronic care.- Methods of health system evaluation and health indicators.- Public health needs and forward-looking services with a focus on community health nursing and digitalization.- Community health care: stakeholders, concepts, and needs-based service development.- Healthy cities: access to participation and inclusion in neighborhoods.- Public health crises and public health emergency preparedness.- One Health environment and health in the context of chronic diseases.- Status quo and development trends in digital health.- Ethical aspects of using technical systems for vulnerable individuals.- Tools for evaluating the usefulness and effectiveness of digital technologies.- V Implementation of Chronic Care.- Implementation of transdisciplinary didactic concepts.- Research-based approaches to Chronic Care Science.- Practice-based challenges in Chronic Care Practice.

About the author

Daniela Schmitz is a junior professor for Innovative and Digital Teaching and Learning Methods in Multiprofessional Healthcare at the University of Witten/Herdecke. Her work and research focus on multiprofessional teaching and learning, strategies for building a shared knowledge base, intergenerational knowledge transfer, and the possibilities and limitations of digital learning in interdisciplinary learning groups.
Manfred Fiedler is a research associate at University Witten/Herdecke. He holds a diploma in social sciences and has been involved for many years with issues related to health management, integrated care, community and public health care, as well as health and social law.
Heike Becker is a pharmaceutical-technical assistant (PTA), has a diploma in social pedagogy (University of Applied Sciences), and holds a Master of Arts degree. She is doctoral student at the University of Witten/Herdecke and works as a research associate at the University of Applied Sciences Düsseldorf. Her research focuses on care situations involving people with dementia and chronic illnesses—particularly those who have experienced displacement, violence, and trauma.
Simone Hatebur is a research associate and is engaged in the topics of healthcare research and interprofessional collaboration in the healthcare system.
Jan-Hendrik Ortloff is researcher, author and site manager of a special residential facility for people with mental illness. He is currently completing his doctorate at the University of Witten/Herdecke on the topic of the didactic anchoring of interprofessional teaching in health science courses. His focus in health-practice is on promoting resilience, empowerment, and health literacy for people with chronic diseases.

Summary

The importance of a professionally and practically appropriate healthcare system for people with chronic illnesses—especially those with multiple chronic conditions—is undeniable in light of demographic changes and the increasing number of older adults with limited everyday competence. Although the German Enquete Commission on "Demographic Change" identified requirements and proposed solutions as far back as thirty years ago, there are still significant gaps in both scientific research and practical healthcare provision. This handbook aims to help close these gaps. It brings together various professional perspectives, highlights the interfaces and tools for collaboration among the different professional groups and healthcare institutions involved in care, and presents methods for care planning and development across diverse care settings and arrangements.
Therefore, the handbook is suitable for practitioners involved in direct patient care as well as for those engaged in healthcare planning. At the same time, it is intended for students, researchers, and educators in the field of Chronic Care Sciences and related disciplines, such as medicine, nursing, therapy sciences, social sciences, and social work.

Product details

• Assisted by: Heike Becker (Editor), Heike Becker et al (Editor), Manfred Fiedler (Editor), Manfred Fiedler et al (Editor), Simone Hatebur (Editor), Jan-Hendrik Ortloff (Editor), Daniela Schmitz (Editor)
• Publisher: Springer, Berlin
• Languages: English
• Product format: Paperback / Softback
• Release: 10.12.2025
• EAN: 9783662722978
• ISBN: 978-3-662-72297-8
• No. of pages: 477
• Illustrations: XXX, 477 p. 49 illus., 37 illus. in color.
• Subjects: Natural sciences, medicine, IT, technology > Medicine > Medical professions; Krankenpflege, Public Health und Präventivmedizin, Nursing, Public Health, health care, interdisciplinary care, Chronic diseases, chronicity, Chronic Care, chronically ill patients