5 Steps We Can Take to Make Leaps Forward with Chronic Care Management
In the United States, the number of people with chronic disease is spiraling out of control. About 129 million have at least 1 chronic disease – about half of which are preventable. Heart disease, cancer, obesity, and hypertension contribute significantly to this list, accounting for approximately 90% of the $4.1 trillion healthcare spend.
We have previously discussed some of the challenges for delivering timely chronic care interventions, including time constraints for primary care physicians and the inability to effectively uncover and support social determinants of health. To date, we have been unable to fully overcome the plethora of obstacles related to chronic care management.
Digital health innovators have come to the rescue with a mind boggling array of tech-enabled solutions, which can be really hard to leverage for older adults. CMS has tried to create additional financial incentives with Chronic Care Management codes, but not enough providers have solved for how to adopt and integrate CCM activities into their practices. And then we have pharmaceuticals, which have proven to make a big impact clinically but fall far short of generating a financial ROI. These levers have all shown promise, but none have fully solved for the challenges of delivering chronic care management.
What’s the Best Path Forward?
Where do we go from here? It’s evident that much has been done to address the management of chronic disease in this country, and that more work is needed. Here are a few thoughts for how we could drive positive change.
Leverage the Measured Self Movement
The growing trend of the “measured self” is something we should consider intentionally introducing into chronic care. Whether individuals are using an Apple Watch or writing things down on paper, the point here is for each patient to be more connected and tuned to what is happening with their bodies and brains. Despite almost ubiquitous access to a variety of technologies that make this easy, we aren’t seeing it prescribed enough to older adults. This might be because some physicians make assumption about seniors and their ability to effectively use technology. In any event, being more aware and having a deeper understanding of key health metrics would go a long way toward individuals being in better position to self manage.
Shift Engagement to the Home
Most older adults with multiple chronic conditions find navigating the healthcare system and seeking support very difficult. That’s why we see more and more energy around bringing care to the home. Chronic condition management is one of the best use cases for shifting support to the home, versus trying to accomplish it all in person or via telemedicine.
An evidence-based analysis published by Canadian researchers back in 2013 demonstrated that in-home care was effective in optimizing the management of chronic disease. Belle recently released data that shows a regular dose of home-based support for chronically ill individuals generates outcomes and value (in terms of ROI) that outpace blockbuster pharmaceuticals, sometimes viewed as the gold standard of chronic care management.
Move from Supporting Decisions to Planting Seeds
One of the most common misconceptions we have about patient behavior is that we assume individuals actually make decisions about their health. In reality, people don’t make decisions to lost weight or quit smoking or take a medication. At least not in a practical, measured way. The industry focuses a lot on “informed decision making” and “shared decision making” but really the more effective model is to think of it as planting seeds. It is more about guided self discovery and nurturing a patient’s volitional desires to lean in to the change that is needed. Most patients glaze over when met with sophisticated concepts and discussions around probability. Weighing pros and cons on health related issues and making active decisions is just not how most people are wired.
To be successful with seed planting, we must establish trusted, longitudinal relationships with patients. That isn’t the normal mode of operations in today’s healthcare system, where transactional care is the default.
Continue the Push to Identify and Address Social Determinants of Health (SDoH)
Being able to consistently identify SDoH needs and then connect individuals to the right community resources is a big challenge for most health plans. An equally troubling challenge is that most community resources lack the capacity to adequately fill the needs of their community. As a result, the brutal reality is that you can effectively identify an SDoH need and connect an individual to the right resource, and still not solve the problem because the resource is already overburdened. In short, this is a multilayered issue.
While we need systemic support to build more capacity among community organizations, it still mission critical to incorporate social-based needs into patient care for chronic condition management. Even the simple fact of knowing a patient has certain SDoH needs can dramatically improve how providers engage with that individual. Systematically tracking the needs of a given population also helps make the case for more funding and support of community organizations.
Keep the Dream Alive for a Single Source of Truth
This is an area where the best outcome is not very likely, unfortunately. The holy grail is full interoperability of data and industrial strength patient registries that guide visits and care plans. We’ve been at this for a while. In the 1990s, there was a move toward health information exchanges. That only traveled so far with so few incentives for providers to share data. Even today, most clinical information systems are selfishly constructed to facilitate each organization’s billing, scheduling and overall business. If we were to truly transition from a logistical and compliance based system to one that is focused on presenting a single source of truth, it would make an incredible difference in our ability to more effectively coordinate care and respond to patient needs. From where we stand today, there is no such system for data on the horizon. That doesn’t mean we shouldn’t push toward the creation of one.
This commentary is not an exhaustive list of what should, or could, be done to push our industry forward and better support individuals with chronic conditions. It is a good starting point, though. Want to share your thoughts on this topic, or learn more about how Belle approaches chronic condition management? Contact us today for a 1:1 discussion.