In HealthAffairs, Ronald Kuerbitz and Benjamin Kornitzer discuss how to develop a sustainable network for the polychronically ill. They say that subsystems with the following attributes should be developed:

• Treatment goals: ”The goal of chronic care is not finding a cure. Rather, it is helping patients manage their condition so they can avoid crises and manage flare-ups.”
• Physician-patient relationship: ”{W}hile the clinician is often called on to do something to an acute patient (i.e. prescribe a medication, perform surgery), he or she must instead find the best way to work with the chronic patient and his or her support network.”
• Evidence-based care: “Networks should develop adaptive learning systems that embrace disease-specific data sets and predictive models to identify leading indicators, identify suboptimal outliers, and develop high value standardization tools, and apply those tools with an individualized patient focus.”
• Multidisciplinary interventions: ”{A} provider network designed to address the social, functional, pharmaceutical, and psychosocial needs of the patient, in addition to traditional medical care, is required.”
• Longitudinal data: ”A hallmark of the polychronic patient is frequent touch points within the healthcare system, from laboratory testing, to hospitalization, and use of specialists. Each of these points of engagement generate data, which can be harnessed to identify leading indicators and transform episodic and reactive care into prevention and management.”
• Measuring success: ”While speed, completeness of recovery, or both are frequently cited measures of success, these are not appropriate for the polychronic patient and their providers.”