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3 Ways to Improve Chronic Care Management

According to the National Center for Chronic Disease Prevention and Health Promotion, six in ten Americans live with at least one chronic disease—and four in ten have two or more chronic conditions. Additionally, 90 percent of the $3.5 trillion spent on healthcare in the United States is for those with chronic or mental health conditions. And that’s before the COVID-19 pandemic changed the global healthcare landscape.

People with underlying chronic conditions are at a higher risk for severe illness or death related to COVID-19, according to the Centers for Disease Control and Prevention (CDC). Yet, many of the care management appointments that those with chronic illnesses rely on to manage their conditions have been delayed or canceled due to the pandemic.

Unfortunately, this could have a disastrous effect on our nation’s most vulnerable patients. For example, research shows that cancer survival rates will likely decrease globally due to delays in care caused by the pandemic. Additionally, it’s been predicted that there will be a surge in demand for behavioral health care, with some organizations already seeing the demand for services go up.

Focusing on implementing and expanding telehealth services, identifying and addressing social determinants of health, and improving care transitions can help improve chronic care management for our nation’s most vulnerable patient populations—despite the pandemic.

1. Implementing & Expanding Telemedicine

Survey data from 185,000 patients across the US has found that COVID-19 has drastically affected patients with chronic illness:

  • 33 percent of patients had to miss or cancel a previously scheduled appointment
  • 21 percent are worried about maintaining their health through ongoing medical care
  • 39 percent report using telemedicine, while 61 percent did not try or were unable to do so
  • 48 percent decrease in physical activity nationwide

While 39 percent of patients who had had their regular access to care disrupted were able to turn to telehealth to receive care, 61 percent were unable or did not try to replace the care they would have otherwise received with telemedicine alternatives.

By implementing and expanding telehealth services, patients with chronic conditions or complex needs can continue to receive chronic disease management care—helping to prevent acute care crises.

2. Identifying & Addressing Social Determinants of Health

Social determinants of health (SDOH) account for 80-90 percent of the modifiable contributors to health outcomes. COVID-19 has only exacerbated factors such as unstable housing, food insecurity, or job loss—and has hit low-income individuals and racial and ethnic minorities the hardest.

Patients struggling with social determinants are lacking basic necessities and aren’t going to be able to successfully focus on managing their chronic conditions unless those needs are met. Doubling down on efforts to identify and address SDOH can ultimately lead to better outcomes by enabling patients to focus on managing their conditions outside of the four walls of an emergency department (ED).

The Providence Health Better Outcomes [thru] Bridges (BOB) program focuses on coordinating care for behavioral health patients affected by SDOH by connecting them with resources they need, such as housing partnerships. By taking the time to understand the patient’s full story and connect them with appropriate resources, Providence has been able to decrease ED utilization for BOB program patients by 41 percent.

3. Improving Care Transitions

For patients who need (and are able) to access in-person care, improving care transitions can help reduce unnecessary utilization or duplicative treatment. The Portland Clinic turned to Collective to improve care for high-risk patients under care management by conducting a pilot program with Providence Health Plan in 2015.

This pilot aimed to better integrate primary care and acute care for vulnerable patients needing chronic care management. Both Providence and The Portland Clinic began reaching out to patients with high-utilization patterns to offer support—an effort that led to a 13 percent reduction in ED visits.

“We identify every patient that goes into the hospital and call them after the visit to make sure they understand what happened to them, have the medications they need, and get follow-up appointments with their providers,” explained Jill Leake, Population Health Manager for The Portland Clinic in a HITInfrastructure.com article. “We are using the Collective data for community collaborative work in Portland. We work with hospitals, health plans, and specialists to make sure we are coordinating care appropriately, reducing duplication of care, and communicating with high-risk, high-utilization patients.”

Ensuring seamless communication and transitions between different care settings also led to a 5.1 percent decrease in 30-day readmission rates for Providence.

Brittany Eastman
Content Marketing Specialist