We frequently talk about care management, which, as defined by the Agency for Healthcare Research and Quality (AHRQ), is based on “appropriate interventions” to “reduce health risks and decrease the cost of care.” When chronic diseases and conditions are present, effective care management with timely interventions becomes even more critical and is the cornerstone of a chronic disease management program.

Chronic diseases are defined broadly by the Centers for Disease Control and Prevention (CDC) as “conditions that last one year or more and require ongoing medical attention or limit activities of daily living or both.” These conditions, which include heart disease, cancer and diabetes, are the top causes of death and disability in this country. About 60% of American adults have at least one chronic disease, the CDC says, and 40% have two or more conditions.

While chronic conditions generally cannot be cured, they can often be controlled. But as our population ages, the growing numbers of people living with multiple chronic conditions is exacting a progressively heavier toll on our healthcare system. For chronic disease management to work the way it’s meant to work—including improving healthcare outcomes and reducing costs—requires the commitment of a variety of entities, starting with the patient.

With that in mind, let’s explore some of the key trends related to chronic disease management, along with strategies for improving it.

Trend: Pivoting to Remote Chronic Disease Management

Among the many consequences of the COVID-19 pandemic was its effect on chronic disease management. Patients with chronic conditions began avoiding healthcare appointments because they were considered at elevated risk not only of contracting the virus but also of developing more serious symptoms. Clinics and other healthcare facilities enforced strict social distancing guidelines by largely placing non-urgent care on hold.

At any time, patients who put off care for their chronic conditions put themselves at an increased risk of those conditions growing worse. That can necessitate an unwanted trip to the emergency room, complicating the situation even further and either creating or intensifying a vicious cycle. But during the pandemic, deferred care was stretched months and even years, with the potential to have a significant impact on individuals with chronic disease now and in the future. This makes it especially important for providers to reevaluate their chronic disease management strategies now and equip themselves with an arsenal of tools to improve health outcomes.

The good news, which (perhaps ironically) the pandemic served to spotlight, is that in-person appointments are not always necessary. The use of telehealth services expanded rapidly at the onset of the pandemic, facilitating safe distancing. But its value has been solidified even further among providers and patients who recognize that digital health technology helps address issues of patient access (for reasons of health safety, mobility limitations, lack of transportation, etc.) and provides important visibility into patient health between office visits (which is essential when managing chronic diseases).

Technologies that have particularly proved effective in supporting chronic disease management include remote patient monitoring tools, as well as digital care management solutions that allow for secure direct messaging, text and video between patients and their care teams.

Remote patient monitoring tools like blood glucose monitors and Bluetooth-enabled blood pressure cuffs help measure and track key patient metrics or vital signs, sending actionable data and insights to the EHR. Secure direct messaging allows patients to get the support they need when they need it. Online patient portals make accessing and sharing health information easier. And online scheduling and reminder tools reduce no-shows and promote follow-through on appointments with specialists. All of this has the dual benefit of reducing call center volumes and sharing information that can trigger timely interventions and prevent avoidable hospital admissions.

Trend: Increased Personalization of Chronic Disease Management

As healthcare strives to become more personalized across the board, the need is felt even more in chronic disease management. Personalized care is holistic care: considering the whole person in the creation of care plans, identifying and addressing social determinants of health (SDOH) that impact one’s ability to manage their conditions, fostering health literacy so the patient can understand their disease, and tailoring a care plan specific to the individual rather than the diagnosis.

Understanding is a two-way street. Patients may need help understanding their condition, treatment plan, medications and need for adherence before they can properly manage and monitor their chronic conditions. Similarly, providers must understand that not all chronic conditions demand the same level of treatment and be flexible enough to modify their approach as the situation warrants.

Likewise, SDOH can weigh heavily on a patient’s ability to adhere to a care plan. A patient who is struggling to put food on the table or living in a “food desert,” for example, will have even more difficulty following a special diet. A patient without reliable transportation may have trouble filling prescriptions, even if the cost of the medication is not a consideration. And various physical, mental, behavioral or financial issues can limit a patient’s ability to adhere to a care plan.

By getting to know the person beyond the condition, healthcare providers and their partners provide more informed and targeted chronic disease management.

Trend: Ongoing Adoption of Value-Based Care Models

The healthcare industry’s continuing shift away from a volume-based payment model toward a value-based care (VBC) delivery model is necessitating more care coordination and collaboration than ever before. This trend, too, is especially important for patients with chronic conditions and comorbidities, as they are likely to be receiving treatment from specialists across multiple disciplines.

Chronic conditions such as congestive heart failure, chronic obstructive pulmonary disease (COPD) and diabetes-related illness tend to be the costliest for hospitals to treat. By transitioning these patients to outpatient settings when possible, hospitals can cut preventable admissions and costs. Providers can manage their patients’ care more directly, guiding them through care transitions. And patients can maintain their independence longer and have their wishes for the type of care they want to receive honored.

This approach requires effective coordination across varied healthcare settings, proactive identification of the most appropriate patients, and attention to SDOH and other root causes of frequent readmissions and emergency room use. Such coordination is a hallmark of clinical pathways, which seek to ensure high-quality care through standardization, while remaining flexible enough to allow for personalized care.

Strategy: Emphasize Self-Management Support Strategies

As we’ve mentioned, the patient’s commitment to personal well-being is an essential ingredient in successful disease management. Many chronic diseases are results of risky behaviors, such as smoking or other tobacco use, excessive alcohol use, poor nutrition or a lack of physical activity. Lifestyle changes may be necessary to get the patient on the road to better health, or at least to slow the progression of chronic conditions.

The Government of Western Australia’s Department of Health offers seven components of self-managing a condition:

  1. Knowing about your condition
  2. Sharing in decision-making
  3. Following an agreed care plan
  4. Monitoring and managing signs and symptoms
  5. Managing the impact on physical, emotional and social life
  6. Adopting a healthy lifestyle
  7. Having the confidence and ability to access community support services

Strategy: Make Patient Education an Ongoing Priority

Depending on the individual patient, education may be beneficial across a wide range of topics, starting with one’s condition and basic health literacy. Other key areas to cover might include:

  • Adherence to monitoring, management and medication plans
  • When to visit the emergency room and when to just call or text the doctor
  • Why referrals are sometimes necessary and how they work
  • Preparing for care transitions
  • The importance of diet, exercise and other lifestyle adjustments

Digital health literacy is also a must, as telehealth, virtual care and remote monitoring become more prevalent. As a June 2020 story in PatientEngagementHIT points out, patients must be aware that a technology exists, know how to use it, see the value in it and be motivated to use it. They also must have access to it; a lack of access to the right technology is another SDOH that affects too many people.

Strategy: Create or Join Community Partnerships

Partnerships among healthcare organizations, community groups, faith groups, and nonprofits can do much to address social determinants of health.

An unhealthy diet is often a key contributor to chronic diseases, which makes addressing this SDOH an important step in managing these conditions. Meals on Wheels America has established a network of more than 5,000 independently operated local programs nationwide.

Food prescription programs are another option, with some offering coupons or vouchers that can be redeemed for fresh produce at farmers markets, groceries or food banks. Others provide boxes of food directly from community farms or gardens. Education can play an important role in these efforts, providing recipes, techniques and tools for preparing foods that may be unfamiliar to people.

Community partnerships can also be effective in addressing needs such as housing, employment, transportation, education and help dealing with substance abuse.

As the numbers of Americans with chronic diseases continues to rise, healthcare organizations would be wise to consider developing programs—or improving existing ones—to help them manage their conditions.

Next Steps for Providers

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