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Community Aspects of Chronic Disease Management Hub
A New Community-based Healthcare Paradigm for the Chronically Ill
The dramatic increase in the number of chronically ill patients and the limited resources directed to their care (in Israel and worldwide) impose a substantial burden on healthcare systems and societies at large.
Chronic conditions, including heart disease, stroke, and diabetes, are responsible for 86 percent of deaths in Europe, and consume up to 80 percent of its healthcare costs.
Projections indicate a further increase in these figures, as Israel’s and much of the world’s population lives longer. Yet, medical science has not sufficiently investigated the management of chronic diseases within the community, nor the resultant impact on both patients and caregivers.
Hub members believe that engaging the community and harnessing community-wide resources is the key to implementing a new model and approach for chronic disease management, based on home care, with all attendant benefits. This proposed paradigm shift has the potential for real regional, national, and global impact.
The Hub’s approach is unique in two distinct ways. First, it defines “community” as broadly as possible, including all stakeholders: the chronically ill patient, his or her population sub-group, health professionals, service providers, informal caregivers, and even the Hub members and other researchers.
Within the framework of this broad community, the vision is to enable more families to provide optimal home care. If all those involved can be instructed to work collaboratively, the life of the chronically ill patient can be dramatically improved.
In one case study, the Hub is working with Bedouin families, offering them immediate intervention and training, with the goal of providing family members with better skills. Hub members are also examining how to best coordinate home care with local hospitals and other medical facilities. The Hub is striving for ways to bring the resources of the community to the doorstep of the patient and caregiver.
A second unique feature of the Hub is the close collaborative ties with the major HMOs providing services in Israel’s southern region. Collaborative arrangements provide access to digital medical records, enabling Hub researchers to track patient data from diagnosis to medical intervention and treatment.
The Hub is committed to changing home care for chronically ill patients by establishing new standards and protocols. For example, the Hub is studying the effectiveness of medical cannabis for pain management in cancer patients suffering from chronic pain.
The overarching goal is to ensure that home care becomes the norm (and no longer the exception) by which all other care for chronically ill patients is measured.

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