that comprehensively addresses not only the individual's health condition but also his or her total social situation. Indeed, beneficial outcomes have been shown to be more likely when personal and social variables are taken into account in geriatric rehabilitation programs (Riley and Riley, 1989).

The concept of quality of life requires considerable refinement before it can become a widely accepted methodological construct. Nevertheless, even if formulated only in general terms, quality of life as an evaluative standard provides a cohesive, transcending concept that can guide the composition, organization, and integration of prevention services for people with chronic disease and for the elderly.

Needs and Opportunities

Although the past 25 years have seen considerable progress in health promotion and the prevention of chronic disease, the need remains for further development and critical evaluation of primary, secondary, and tertiary prevention efforts. Health promotion and other primary prevention efforts that begin at the earliest stages of life are among the most effective and are applicable not only to those who are free of disease or impairment but also to those with disease and disabling conditions. Moreover, risk-reducing, health-promoting activities are important for the elderly with chronic disease because they are already predisposed to functional limitation and disability. In this regard, it should be noted that the Health Care Financing Administration is currently conducting several Medicare prevention demonstration projects. The second interim report on these projects is due to Congress in the spring of 1991, with the final report scheduled for 1993.

Secondary prevention measures, which seek to halt, reverse, or at least retard the progress of a condition, and tertiary prevention measures, which concentrate on restoring function and increasing personal autonomy in people who are already limited in functional capacity, are especially important for people with chronic disease. Combined with appropriate health promotion efforts, these measures constitute the building blocks of chronic disease management. Although the particular elements are dictated by the type and number of conditions present and their predicted course and by the features of an individual's social and environmental surroundings, the management of chronic disease focuses on quality of life, not just health status, and involves self-care, measures to prevent disease complications, counseling and other measures to foster psychosocial coping, and modification of the environment to accommodate functional limitations.

Researchers and service providers have little epidemiological data to guide their efforts to identify effective interventions on which to build chronic disease management plans. The information that is available describes the



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