Managing Patients with Chronic Diseases: How to Do it Right?

Abhinav Shashank
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The provider community burns midnight oil to improve patient outcomes and further the dream of value-based healthcare. However, if you take a look at the average healthcare utilization expenditure, chronic diseases account for 75 percent of all healthcare spending. That’s more than $3.5 trillion alone, and every 6 out of 10 US adults is living with a chronic condition. Given the fact that managing chronic diseases occupy a large chunk of the nation’s average healthcare spending, a myopic approach isn’t going to help in the future. By 2030, the US would be accommodating to the healthcare needs of 77 million+ people above 65 via Medicare. 

Therefore, it’s high time to create a failsafe strategy to care for the population dealing with chronic diseases and strengthen associated programs. Let’s take a look at the state of chronic disease management.

                                                                                                                                                                              Source: CDC

Pitfalls in Chronic Care Management

  • Adherence to Only Short Term Goals

To excel at effective chronic care management, providers must focus on the long-term well-being and care needs of the patients. However, the Affordable Care Act offers incentives to reduce 30-day readmissions post-discharge. Therefore, providers need to modify their care management strategies post-discharge, leaving enough room for care to cater to the needs of high-risk populations. It’s time to look for a solution that offers complete, real-time visibility into patients’ activities after the discharge to contain the chances of a relapse.  

  • Lapses in Accommodating Comorbidities

Multiple chronic conditions have associated comorbidities that can lead to both long-term complications and increase treatment costs. A leading Mckinsey research suggests that 71% of patients with heart failure have hypertension, 37% have diabetes, and 53% have hyperlipidemia. So, treating the prevailing condition is only a job half done, and providers need to step-up their strategies to go upstream and engage with patients that are either at high or low risk of developing a comorbidity in the future. Addressing comorbidities on time will ensure that the patient remains stable in the long run that cuts down the risk of emergency visits.

  • Inadequate risk stratification

Risk stratification mainly caters to the needs of high-risk patients and fail to factor rising-risk patients. While providers leave no stone unturned in providing the best clinical treatment inside provider facilities, that’s not all. There are additional factors such as Social Determinants of Health that are not an integral part of risk stratification algorithms and later lead to inefficient chronic care management plans.

  • Primary care Vs. speciality care

Primary care providers often face difficulty in deciding whether a patient can be treated in a primary care setting or requires intensive care. Taking the right call between the two often becomes the reason for higher costs because of an increase in acute care utilization.

How Can Providers Get Pass these Obstacles?

Patient identification analytics

For chronic care management to yield desired results, providers must be able to identify primary care subjects while patients receive acute care. For instance, in a traditional healthcare setting, patients consult a healthcare provider for treating a chronic condition. 

Patient identification should be in a way that providers can take an intelligent, data-backed decision whether a patient receiving primary care would become a chronic care subject in the future. For instance, a person receiving treatment for joint pain can become a candidate for joint replacement, or someone with an advancing kidney disorder could soon require a kidney replacement. 

Condition-based care

Interdisciplinary coordination is the need of the hour for effective chronic care management, which stretches beyond episodic care. This involves creating detailed patient personas to factor future risks, habits, and behavioral patterns to ensure patients engage well in their care journey through a close network of providers, equipment, and ambulatory services; available near to the patient and availed whenever required.

Payment models in chronic care management

Although Medicare introduced an exclusive reimbursement code for chronic care in 2015, a survey reports that only 51 percent of primary care providers know that they can be paid monthly for non-face-to-face visits that involve patients receiving treatment. The survey also hints that the complexity of reimbursement codes, the amount of paperwork or inadequate incentives are a few roadblocks on their way to introducing chronic care management.

The Road Ahead

Technology has been disrupting healthcare in the past and can strengthen chronic care management programs as well. While the focus for most providers lie on compliance, taking a step ahead and having a dual focus on high-risk patients and healthy people can bring a landslide difference to chronic care programs. Care gaps, if any, needs to be addressed in real-time while patient reporting on care journey has to be spot on. 

To learn more about how providers can excel at chronic care management and set new examples, get a demo.

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