2018-12-18

How providers can improve chronic disease management

How do I know which patient to reach out to? Which patients are no longer following their self-management plan? Will my company achieve the financial incentives associated with quality? How do I measure performance and outcomes? What additional information do care coordinators need to be successful? These are a few of the concerns that keep healthcare executives up at night.

One of the major problems amplifying these concerns is that the system is set up for episodic care and not continuous, coordinated care. This inadvertently drives up the cost of care for patients and for the industry as a whole—particularly for patients with chronic conditions, which is a huge contributor to high costs. In fact, according to the U.S. Centers for Disease Control and Prevention (CDC), 90% of the nation’s annual healthcare expenditures are for people with chronic and behavioral health conditions.

The complexity of self-management compounds the problem, placing additional financial strain on patients and the healthcare system. Providing patients with education and community resources to help them engage in appropriate self-care behaviors is also critical.

What can be done to support patients with chronic disease(s), and at the same time, help to correct expenditures? For this to occur, the system needs a few key supports:

  1. Embedded resources with accountability to improve chronic disease management and outcomes
  2. The right tools, which offer real-time data that is available to the healthcare provider and the patient
  3. Connectivity with community resources to address barriers to self-management

Who is the Care Coordinator?

In the busy atmosphere of a provider organization, who would be responsible for coordinating care for patients with chronic conditions? This has fallen into the hands of a care coordinator. The care coordinator is an individual selected by the provider organization to assist in managing and organizing a patient’s care. This person works with the patient and family to ensure that all needs—physically, psychologically and socially—are met. Not only is the care coordinator working with the patient and family, but they are also responsible for quality measures and metrics required by practice contracts.

How does a care coordinator ensure that all quality measures and incentives for each contract have been met, while ensuring that the patient is understanding and caring for themselves in the correct manner? To do this, the care coordinator must be able to easily identify patients that are at-risk and efficiently obtain an overview of patient needs. This is where the right technology comes in.

Technology to Support Care Coordination

To be successful as a care coordinator, specific technology resources are needed. These resources must be easily accessible, while helping to manage and report on care that is in progress and has been completed. This need for on-demand data has forced healthcare beyond the pen and paper to the electronic medical record (EMR). The main purpose of an EMR is to systematically collect key information about a patient’s health and make it available for review to ensure comprehensive, quality healthcare. This move has created efficiencies, but it is not always enough to ensure all contracted metrics are accessible and reportable.

For the care coordinator to improve outcomes and ensure all measures are met, a care management platform is needed. This includes a clinical information system that captures, manages and provides details on condition-specific information. For example, it captures data on lab results, medications, tests/screenings, education interventions, and more. In addition, these systems not only need to capture data, but they must also allow for tailored communication to the patient. Couple this with the ability to send providers information on needed tests and results, and the chronic disease management process becomes more efficient and less costly.

It’s important to note that care management platforms are designed to supplement care—not replace a medical record. Care coordinators can access the platform to determine what interventions are needed or overdue based on predetermined guidelines. These technologies provide better efficiencies than an EMR on its own.

Beyond the Platform

Armed with information on the patient’s condition and needed interventions, the care coordinator must now engage the patient and family or caregivers. Patients and their caregivers must be educated on the condition(s) and corresponding self-management practices through a multi-faceted approach, as no two patients learn the same way.

As the care coordinator educates patients, they also need to assess any barriers to self-management that are present, including patient-specific social determinants of health such as housing insecurity and food insecurity that create health challenges for the individual person. Addressing these non-health-related issues can significantly improve a person’s well-being.

It’s been shown that chronic disease can be alleviated with simple lifestyle changes. The CDC estimates that eliminating four risk factors—poor diet, inactivity, smoking and alcohol abuse—would prevent 80% of heart disease and stroke, 80% of type 2 diabetes and 40% of cancer. Connecting patients with the appropriate community resources, such as disease management coaching, preventative services, billing education and transportation, is extremely important to ensuring success in managing their health.

The Future of Chronic Disease Management

The right people, the right technology and the right community resources are key to lowering costs and improving outcomes for people with chronic conditions. With these in play, the support of chronic disease is headed in a new direction. The focus can then shift from reactive, crisis-based care to prevention of deterioration.

For most provider organizations, the state of technology to support disease management and care coordination is insufficient. Currently, this is accomplished through various tools and technologies, plus an EMR, and is labor intensive. What is needed is a dynamic technology that adapts as new information about a patient is entered into the system. Not passive lists of data—the dreaded “magic spreadsheets”—that only give point-in-time data. The future of better chronic disease management needs a constantly evolving care plan that identifies challenges, provides solutions to mitigate them, sets patient-specific goals and creates accountability for the person’s health—all in one system.

Texture Health has built a care coordination platform that takes in multiple pieces of information, stratifies the population, identifies needed interventions, provides patient engagement and education, and allows for accurate documentation and reporting. For more information or to schedule a demo, contact us.


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