Person-centred integrated chronic disease management: quality of care, patient experience and clinical continuity

Abstract

Introduction: Chronic diseases require healthcare models capable of responding to multimorbidity, long-term follow-up, fragmented services, and active patient participation. Recent evidence indicates that integrated care can strengthen coordination and improve outcomes when professionals, levels of care, and longitudinal follow-up are effectively connected. In parallel, self-management represents an important component for maintaining therapeutic behaviors and functional capacity. Objective: To systematically analyze the impact of contemporary chronic disease management strategies on quality of care, patient experience, continuity, and clinical outcomes. Methodology: A systematic review was conducted through structured searching, predefined eligibility criteria, critical appraisal, and domain-based data extraction. Integrated models, self-management, digital health, telemonitoring, person-centered care, and interdisciplinary coordination were examined. Results: Evidence showed that integrated interventions achieve better outcomes when longitudinal follow-up, education, clinical communication, and coordination are combined. Digital tools have expanded opportunities for chronic disease management and follow-up, although patient experience depends on accessibility, digital literacy, and technological adaptation. Remote monitoring facilitates clinical follow-up and early identification of changes, particularly when integrated into healthcare workflows. Conclusions: Effective chronic disease management requires person-centered models integrating clinical care, self-management, continuity, digital technologies, and interdisciplinary collaboration. Effectiveness depends on contextual adaptation, relational continuity, organizational capacity, equitable technological access, and active patient participation throughout long-term care. Long-term benefits are more likely when services integrate patient preferences, multidisciplinary accountability, and responsive follow-up across settings and stages of illness.