Healthcare Analytics, Population Health Management, Healthcare Big Data

5 Ways to Turn Chronic Disease Management Knowledge into Action

Chronic disease management is one of the healthcare system's most challenging tasks. How can providers use innovative strategies to reduce spending and improve wellness?

In order to cut the skyrocketing costs of chronic disease management and reduce the burdens of diabetes, heart disease, asthma, and other conditions on the patient population, providers must take advantage of opportunities to translate the healthcare system’s knowledge into action, states a new white paper by the Partnership to Fight Chronic Disease.

Chronic disease management and population health management

More than half of Americans is currently living with at least one chronic disease, the report states, while nearly a third of patients are managing two or more of these conditions.  In addition to reducing quality of life for patients and their families, the costs of caring for these complex cases are straining the industry to its breaking point.

Eighty-six cents of every dollar spent on healthcare is devoted to treating or managing a chronic condition, and the average yearly cost of care may increase by $2000 for each additional disease a patient experiences. 

Previous research has found that patients with chronic disease can cost seventeen times more than other users of healthcare resources, making it critically important to streamline care delivery to help patients receive maximum benefit from preventative services and lower-cost contact with their providers.

The Partnership to Fight Chronic Disease, which includes organizations such as the American Hospital Association, NAACP, American College of Preventive Medicine, and US Chamber of Commerce, suggests five ways that healthcare providers can leverage existing resources, emerging reform initiatives, and community relationships to improve chronic disease management for patients, their families, and the care continuum as a whole.

Make chronic disease management and prevention a top priority

Many of the most common chronic diseases can be linked to patient lifestyle choices, missed opportunities to deliver preventative care, and a health system that does not prioritize well-care over sick-care due to financial pressures.

“Our health care system needs to align incentives to encourage payers, providers, employers, and individuals to better prevent, detect, treat, and manage chronic diseases — both physical and mental — before they become acute, costly problems,” the report states, urging providers to take advantage of new value-based reimbursement models that highlight the necessity to deliver robust chronic disease management and complete preventative care.

Providers who receive more financial incentives for avoiding adverse events, managing populations holistically, and delivering preventative services that may forestall the development of diabetes or heart disease have already shown that the strategy can produce meaningful results.

Care coordination and population health management initiatives such as the patient-centered medical home can reduce unnecessary spending while raising quality measure performance – and produce the extra benefit of preparing providers to accept financial risk with accountable care arrangements or value-based contracting.

Increasing communication between care sites, including behavioral health facilities, is another way to ensure that patients are receiving all the services they need to manage their chronic conditions without being subjected to duplicate testing, unnecessary hospitalizations, or gaps in information that may impact decision-making.

Invest in big data analytics and precision medicine

Continued innovation in the health IT arena may also help providers reduce inefficiencies and improve the health system’s ability to proactively identify risk and coordinate care.  By investing in emerging technology tools like big data analytics and genomic testing, providers can conduct early outreach and consistent follow-up, monitor and manage patients more effectively in their homes, and cultivate a deeper understanding of how, why, and where chronic diseases develop.

Health IT tools can deliver more accurate and timely information to the point of care, collect and analyze big data, and provide clinical decision support capabilities that may help clinicians understand how to better treat their patients.

The White House’s Precision Medicine Initiative is one project that is bringing together federal agencies, healthcare providers, and IT vendors in pursuit of these goals.  The Initiative hopes to accelerate research initiatives and provide the analytics infrastructure necessary to bring population health management to an entirely new level.

Improve patient access to care by ensuring they can pay for it

Many chronic disease management patients experience socioeconomic challenges that make it difficult to regularly access – and pay for – healthcare services.  These patients may delay necessary care or skip visits all together if they do not have sufficient financial resources, but putting off management of chronic diseases could simply lead to more costly and serious complications down the line.

Even patients covered by insurance may not be able to handle their medical bills.  High deductibles and copays often make out-of-pocket expenses unmanageable for patients.  One industry poll found that 14 percent of adults have avoided seeing a provider due to the costs involved, and a nearly a third of younger patients have ignored a general health complaint over fears that addressing the situation would be too expensive.

 The healthcare system has the opportunity to improve this state of affairs by removing barriers to preventative and chronic disease care, the Partnership says.  Providers should educate patients about health insurance options during federal open enrollment periods, and can also connect with community services to ensure that patients have access to care where they live.

“Community-based programs provide aging in place services, disease management coaching, and preventive care services in lower cost settings with proven results,” the report says. “Integrating these services more closely with the healthcare system can increase support for patients and families while reducing health care costs.”

Make chronic disease prevention and management a family affair

Chronic diseases affect patients during every stage of their lives, and may start in childhood.  Obesity rates among children have tripled since the 1970s, says the Partnership, and have been contributing to the development of diabetes and heart disease later in life.

“Poor health status headed into adulthood presents challenges for employees and employers and hinders economic growth overall,” the report adds. “Preventable and poorly managed chronic diseases also drive workplace health care costs, including productivity losses. Better management of chronic diseases like depression and addressing risk factors such as obesity and smoking could help qualified workers stay on the job, improving competitiveness of the American workforce.”

Elderly patients also suffer from chronic diseases at an extraordinarily high rate, and may experience significant self-care challenges due to the normal process of aging.  These patients may rely heavily on family members for transportation or help with decision making.  The Partnership estimates that 80 percent of home care is performed by family caregivers.

The healthcare system can address these concerns by educating parents about strategies for choosing healthy diets for their children and keeping them active, as well as providing support for caregivers in the form of care coordination services, information and education, and opportunities to network with others in a similar position.

Learn from successful initiatives to grow best practices across the nation

Perhaps most importantly, healthcare stakeholders must share their experiences, successes, and failures with their peers in order to grow the body of knowledge available to others. 

“We aren’t doing enough to tap into that knowledge and to replicate nationwide those programs that work,” the Partnership states. “The need to replicate successful programs is particularly acute in underserved areas and with populations in which health disparities persist, lowering health status and leading to lost economic opportunities.”

Providers should take a collaborative approach to chronic disease management by regularly meeting with business partners and taking advantage of resources, like their payers or local Regional Extension Centers, which can help them meeting the growing challenges of serving their patients.

As the healthcare system becomes more tightly aligned around value-based reimbursements, new partnerships within the community are bound to follow.  Providers who take advantage of current thought leadership may be able to help patients change their behaviors, manage their chronic conditions appropriately, and reduce financial strain on the industry at large.

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