today, more than half of the U.S. population Have at least one chronic disease, and nearly 30% have multiple chronic diseases. These chronic diseases — including heart disease, high blood pressure, cancer, diabetes, and, increasingly, long-term infections — are not only complex to manage, but also expensive.according to a Milken Institute reporttreating chronic diseases costs payers and consumers more than $1.1 trillion in direct care annually.
And it will only get worse. With an aging population and a shortage of healthcare workers, our healthcare system is unable to provide the proper care for chronically ill patients as usual—that is, relying on occasional check-ups and DIY management at provider sites. These methods fail to provide the consistent care people need, manage their condition effectively between appointments, or prevent acute symptoms that lead to expensive emergency room and hospital bills.
To manage chronic care at scale, we must look at the problem with fresh eyes. We need to evaluate the new digital solutions we have and consider how these innovations can give way to more efficient and effective models of care delivery.
Issues in Chronic Disease Management Today
In most health systems, providers manage chronic conditions using the same basic model that every consumer knows. Patients make an appointment with their doctor, the doctor assesses the patient’s condition and proposes a treatment plan, and the patient is tasked with managing their own care.
This model has many problems with long-term care. On the one hand, when people are left alone, they often have difficulty following their recommended treatment plans. Sometimes they don’t understand what they should do, and sometimes they have a hard time following their doctor’s advice. If people don’t manage their disease properly, symptoms can worsen, sending them to the hospital. Not only is this harmful to patients, it is also expensive to the healthcare system.
Even when patients follow their doctor’s instructions completely, their health can still deteriorate for reasons beyond their control. If the deterioration is not detected early, chronic patients are often admitted to the emergency room. This also leads to poor patient outcomes and high cost of care.
The case for reimagining chronic care services
To truly transform healthcare costs and outcomes, we need a more integrated model of healthcare delivery. This should fill the gap between scheduled appointments and facilitate more regular connections between healthcare consumers and their providers.
This model of care is still largely in its infancy. Chronic care health plans are largely limited to patient communication solutions — messaging between providers and patients via portals — and telehealth encounters: Zoom meetings between patients and doctors. While occasional messaging and occasional telehealth services can serve their purpose, they do not provide the comprehensive, proactive care that chronically ill patients need to stay away from the hospital.
Regular patient monitoring and enhanced engagement are required to track disease emergence and evolution. With real-time insights, providers can take a more proactive approach to managing care and prevent costly hospital visits when symptoms are not managed properly. In an evolving healthcare ecosystem, healthcare systems are still uniquely able to deliver this longitudinal model of care because chronically ill patients may require a wide range of services over time.
Longitudinal Nursing in Action
How can these gaps be filled without exacerbating clinician staffing pressures? Consider this patient journey:
Carroll, a congestive heart failure patient, has been to the hospital twice in the past three months with excess fluid and shortness of breath. The Cardiology Department felt Carol was out of control of her disease, so they asked her if she would like to enroll in a chronic care program that includes a mobile app and a Bluetooth-connected scale.
In addition to tracking her weight, Carol receives regular reminders through the app to report her symptoms, as well as task and activity reminders. When necessary, she exchanges information or makes video calls with her provider through an app on her phone. With this digital chronic care plan, Carol can better manage her condition and successfully avoid hospitalization.
A year later, her condition worsened and required more urgent care, and Carol was assigned to a home hospital The team provided her with passive, continuous vital signs monitoring and essential home services. The home hospital was able to see trends in her vital signs over time because it was all in sync with the EHR. As a result, her care team has the comprehensive details needed to understand Carol’s history and the best way forward.
For patients with more serious illnesses like Carroll, digitizing home care could significantly reduce the frequency and total number of hospital visits. By creating new models that track and engage patients more continuously, we can slow disease progression, improve patient outcomes, and unlock more efficient operating models for health systems of all shapes and sizes.
The pattern has become more familiar in the pandemic as hospitals find ways to keep in touch with patients more frequently at home. But for this approach to be widely available in the future, new payment structures are needed.
Today, most contemporary payment structures do not support this approach to care: they compensate for visits and admissions, but generally do not support low-touch care between encounters. Value-based payment structures and readmission penalties may incentivize longitudinal care approaches. Progress has been slow, however, and even internal accounting can be an obstacle to deploying this proactive and healthy approach. What is needed is leadership: a wealth of published evidence demonstrates the clinical and economic value of integrated care, but achieving this requires a bold and broad stakeholder-supported commitment.
Image credit: AJ Watt, Getty Images
