Chronic Care Management

Where does chronic care go from here?

Paul Grundy MD, MPH, FACOEM, FACPM
Wed 16 December 2020
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As the Coronavirus Disease 2019 (COVID-19) public health crisis continues to re-shape health care delivery—largely through increased utilization of telehealth services—payers and providers are grappling with how best to navigate dramatic shifts in the system.

America’s chronic care facilities have been overwhelmed by COVID-19 as well. According to recent data aggregated by The New York Times (NYT), roughly one-third of all Coronavirus deaths have occurred in these facilities (Yourish et al., 2020). As of mid-May, NYT estimated that the virus had infected more than 153,000 people at some 7,700 long-term care facilities, and there have been 28,100 deaths.

Although the long-term effects of COVID-19 are unknown, providers are already adopting a new normal—prioritizing frontline healthcare workers’ needs, enhancing infection control protocols, increasing supply inventories and altering social isolation practices.

Some highlights of the road ahead for care delivery include:

  • Specialized care will become virtual, improving access and affordability and disease-focused solutions will flourish.
  • Asynchronous communication, such as text and media messages, will be utilized much more, both for patients to consult with their physicians and for physicians to consult with other specialists.
  • Employer health offerings will become increasingly virtual and home-based.
  • AI-based triage tools will be more mainstream among physicians and healthcare providers.
  • Virtual healthcare will ensure the accessibility of services to rural populations.
  • Remote patient monitoring (RPM) will be an integral part of patient care going forward.
  • A greater emphasis on social and demographic determinants of health and how they affect a person’s health status will guide the delivery of care.
  • Providers will transition to more virtual care and acceptability towards other digital health interventions will grow.

Telehealth and Remote Care: A shift to virtual chronic care management

The current scenario has created enormous pressure on the entire healthcare system, but the long-term care system for both younger and older people has been gravely affected. Nursing homes and chronic care facilities are facing many challenges. Organizations across the continuum of care are facing cuts in reimbursement from Medicaid and other key payers. For example, new rules that abolish automatic 30-day levels of physical therapy as part of a patient rehabilitation program will drastically reduce reimbursement levels.

Telehealth can maintain the continuity of care and can be strengthened with chronic care management (CCM), helping avoid the negative consequences of delayed care. Coupling telehealth for chronic care management, organizations can address many of these COVID-19 pain points head-on.

Under a value-based system such as capitation, providers are incentivized to focus more on preventive care today that will help avoid costly complications tomorrow. For telemedicine to truly take off for chronic disease management, the U.S. healthcare system must boost investment in these types of alternative payment models. Doing so will clear the path toward a healthier post-pandemic future.

Today, healthcare is all about reducing the overuse and misuse of healthcare services, which in turn, minimizes costs. Remote patient monitoring (RPM) has assisted in making this possible. RPM is a technology used to monitor a patient’s health remotely when they are not in their physician’s immediate care. By passively or actively collecting data from patients wherever they are, providers can realize benefits, from reduced readmissions to shortened hospital stays and improved clinical outcomes.

The United States, along with other countries around the world, is embracing remote patient monitoring technology. With advances in non-invasive sensor technologies, growth in availability and adoption of cellular connectivity and the falling costs of embedded communications devices, it will continue to gain further adoption and become a critical component of the new healthcare models, including those around accountable care, among others. It will lower healthcare costs, emergency room visits and hospital readmissions, therefore improving the quality of healthcare services and outcomes in the industry.

Conclusion

As healthcare delivery is becoming more population-specific, personalized technology will be the key transformative element. To better manage long-term care, a greater focus on data created by the patients, and using that data to create actionable insights is essential. Healthcare data platforms such as the FHIR-enabled Data Activation Platform by Innovaccer bring multiple solutions such as remote care, patient engagement and chronic care management to one place. This simplifies use and improves collaboration in care delivery, making healthcare organizations future-ready.

To learn more about the platform click here.

Schedule a demo to find out how a data activation platform can transform practice and care delivery at your organization.

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