Chronic Care Management Marries Big Data

Abhinav Shashank
Fri 16 Dec 2016
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On an average, chronic conditions claim 7 out of every 10 deaths in the United States, accounting for more than 1.7 million Americans every year. The amount of money being spent to treat patients with chronic diseases is skyrocketing; according to CMS, 93% of United States’ total Medicare spending is distributed among beneficiaries with multiple chronic conditions. These stats are truly reflecting the real picture and make us wonder why there is need to drive focus towards chronic care management.


Prevalence of Chronic Conditions in People

A chronic condition is an illness or a disease that persists for a long time – as per the definition of the U.S. National Center for Health Statistics, a chronic disease is the one that lasts for more than three months. CMS has provided a list of 19 chronic conditions, not limited to them, like Alzheimer’s Disease, Cancer, Diabetes, HIV/AIDS, Schizophrenia and more. According to the latest Commonwealth Fund brief, the healthcare industry is unable to meet the needs of patients with chronic conditions:


  • 47% of the surveyed patients had to go to the emergency room multiple times in the past two years.
  • 48% of high-need patients were hospitalized overnight.
  • As of 2012, 117 million people had one or more chronic conditions and accounted for 86%, a major share of entire healthcare spending.
  • About half of U.S. adults have at least one of the major risk factors leading to heart attacks or stroke.


Chronic care management incorporates the insights and studies conducted over the years to help patients with chronic conditions and focuses on developing exclusive care plans, helping patients achieve longevity and quality of life.


Need for Transformation in Care Plans

For many years, the healthcare industry might have evolved and successfully oriented itself to suit the needs of patients with acute episodes but when it comes to treating chronic conditions, the kind of medical intervention present today sometimes prove ineffective, and, need to redesign care plans arises.

1.) Fragmentation in care-delivery and delayed care

According to the Commonwealth Fund report, 58% of the respondents did not have access to an informed and updated care coordinator.

2.) The rise in disease-specific risk factors

There has been an increase in conditions like obesity and diabetes which in turn lead to other cardiovascular and renal diseases.

3.) Inappropriate care settings

Either owing to delay in care or unawareness or inhibited access, 19% of high-need respondents went to an emergency room instead of a physician’s office.

4.) Increasing costs of care

The healthcare costs for people with chronic conditions has been increasing dramatically – Medicare beneficiaries may see from four to fourteen physicians a year!


Due to these reasons, and not being limited to them, many care facilities are now moving towards correcting the many deficiencies in the current management of chronic diseases.

In January 2015, CMS introduced a Chronic Care Management model that proposes to reimburse providers every month on delivering care services for Medicare beneficiaries diagnosed with two or more chronic conditions. This call by the CMS is more or less asking providers to orient their services to deliver chronic care and join this cause for action, for the healthcare system needs to change substantially to enable coordination between systems and provide care.


Challenges in Implementation of Chronic Care Management

There are a lot of limitations still lurking in the healthcare industry, hindering the development of chronic care management plans:

1.) Troubles in long-term care plans

The healthcare industry still lacks a lot when it comes to developing care plans and implementing them. Lack of follow-ups, alerts, and an altogether poor patient engagement leads to poor health outcomes.

2.) Insurance Plans

Most private insurers have similar provisions such as Medicaid – post-episode care and personal care are usually not covered in the Medicare program, and this trend was picked up by most third-party payers.

3.) Lack of multidisciplinary care teams

People with chronic conditions don’t only need in-patient care, but a regular and constant follow-up plan with exclusive support from family, friends, and providers. According to a report, only 35% of patients believe it’s easy to get medical care after visiting an ER. 

4.) Uncoordinated health care

Inadequate care coordination not only costs $45 billion to the healthcare industry but also goes as far as claiming lives. Although communication between providers is paramount, it is often overlooked.

5.) Lack of interoperability between healthcare providers

It is extremely important that different providers tending to one patient have flawless communication between them. According to a recent study, 40% providers believe that lack of coordination in information exchange causes their patients problems.


Technology of Future: How AI facilitates Chronic Care Management

Big Data technology is no less than a game-changer in healthcare today. Health IT is a booming field and has opened up possibilities which one never thought even existed. One of the most recent and most talked-about developments in health IT is Big Data and Artificial Intelligence, and if we can tap the immense potential AI has, the picture of chronic care management will undergo a major change.

An AI-assisted platform can help in:

1.) Predictive Care

Predictive data analytics can help the organization track its performance six months from now and see where it will stand in coming time. It could drill down to provider/facility level and work on the weak links.

2.) Risk Stratification

With an AI assisted platform, patients stratified on the basis of risk could be engaged easily. For instance, if there is an at-risk patient, the platform could identify him/her and automatically plan an intervention for such an individual!

3.) Coordinating Efforts

So if there are ‘n’ number of at-risk patients and a certain number of patients being discharged from hospitals, the health coaches would be directly informed about this via push notifications and a health plan for post-acute episode could be designed.

4.) Intuitive Care Plans

When a Health Coach gets in touch with the patient, he would have an automated survey to conduct specific to a patient and case. Based on the response given by the patient, a care plan would be designed for the patient. Consider a patient who has just been discharged, the first course of action would be the platform notifying health coach about the case. Then, health coach would call the patient and enquire about the basic amenities such as travel facility, caretaker, medication, follow-up visit, etc. and based on the responses by patient a care plan will be generated for weeks or months depending on the case.


The Road Ahead

Chronic care management is all about patient-centric care. The fact that chronic care management has to incorporate insights from caregivers along with data analytics and making the care process centered around the patient and focus on improving the quality of their life.

Big Data allows us to explore a whole new level of possibilities in the field of healthcare. Imagine a care delivery plan where patients are not only engaged in time but see improved health results at affordable costs. That is the dream. That is the goal. Doctors comfortable with technology and making wonders happen! Wouldn’t that be great?


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Tags: Big Data, Data Science, Healthcare, Integration
Abhinav Shashank
Chronic Care Management Marries Big Data

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