Shahrekord University of Medical Sciences Journal of Multidisciplinary Care 2783-3852 14 3 2026 09 14 Integrated Multidisciplinary Care for Chronic Disease Management: A Holistic Model for Patient-Centered Outcomes 131 136 10.34172/jmdc.1413 EN Shivansu Sachan https://orcid.org/0000-0002-9893-8018 Praveen Katiyar https://orcid.org/0000-0001-5902-8073 Journal Article 10.34172/jmdc.1413 2025 06 17 2026 04 21 Introduction: Non-communicable diseases, such as diabetes, hypertension (HTN), and chronic obstructive pulmonary disease (COPD), account for over 70% of global deaths and 65% of total mortality in India (1). Fragmented, physician-centered healthcare systems frequently result in delayed care, poor treatment adherence, and high hospital readmissions. This study aimed to evaluate a structured multidisciplinary care model integrating medical, nutritional, psychological, and community-based interventions. Methods: A mixed-method longitudinal study was conducted from January 2023 to June 2024 at Lok Nayak Hospital, New Delhi. Overall, 200 patients diagnosed with type 2 diabetes and at least one comorbidity (HTN or COPD) were selected using systematic random sampling. Quantitative data were collected using hemoglobin A1c (HbA1c) values, body mass index (BMI), hospital readmission rates, Morisky Medication Adherence Scale (MMAS-8), and WHOQOL-BREF satisfaction scores. Qualitative data were analyzed using thematic coding from 30 in-depth patient interviews and 12 healthcare provider interviews. Data were statistically analyzed using SPSS 26 (P < 0.05). Results: After 12 months of multidisciplinary intervention, the mean HbA1c and hospital readmissions decreased from 9.2% to 7.8% (P < 0.001) and from 38% to 16%, respectively, and BMI reduced by 5.1%. However, medication adherence increased from 52% to 79%, and overall patient satisfaction improved from 72% to 91%. Qualitative findings revealed improved trust, enhanced communication, and greater emotional support. Conclusion: The multidisciplinary care model significantly could improve clinical outcomes, adherence, and patient satisfaction in chronic disease management. In general, this approach is feasible, scalable, and suitable for integration into India’s public healthcare system.