Decision-Support Frameworks for Integrated Chronic Disease Management: Clinical Decision-Making, Multidisciplinary Coordination, and Digital Health Applications

Background: Chronic diseases such as diabetes, heart failure, and chronic kidney disease are leading causes of morbidity and mortality worldwide. Fragmented, siloed care pathways contribute to poor adherence, frequent hospital readmissions, and reduced quality of life. Integrated care models involving nurses, pharmacists, and nutritionists have emerged as promising approaches to address these challenges through coordinated clinical decision-making and multidisciplinary collaboration.Objective: To synthesize evidence on the impact of multidisciplinary care involving nurses, pharmacists, and nutritionists in optimizing chronic disease management and supporting coordinated clinical decisions, with a focus on adherence, readmissions, and quality of life outcomes.Methods: A narrative review of literature published from 2018 to 2025 was conducted using PubMed Central, Google Scholar, and institutional repositories. Priority was given to randomized controlled trials, systematic reviews, and consensus guidelines. Outcomes of interest included HbA1c reduction, blood pressure control, hospitalization rates, and quality-of-life measures. Quantitative results were extracted, summarized in tables and figures, and a network diagram illustrated team interactions.Results: Nurse-led interventions reduced hospital readmissions in heart failure (25.5% → 5.6%) and improved glycemic control in diabetes (HbA1c 7.92% → 6.94%, P < 0.01). Pharmacist-led programmes lowered hospital admissions (0.78 → 0.54, P < 0.001), improved medication adherence, and decreased systolic blood pressure by ~6.8 mmHg. Nutritionist-delivered medical nutrition therapy reduced HbA1c by up to 2.0% in type 2 diabetes and slowed CKD progression, while also addressing dietary-related risk factors for heart failure readmissions. Integrated multidisciplinary models demonstrated enhanced patient satisfaction, improved self-management behaviors, and overall cost savings.Conclusions: Broader implementation requires addressing policy barriers, workforce training, reimbursement challenges, equity in access, and effective clinical information-sharing mechanisms to support multidisciplinary decisions.