Gaps in Chronic Disease Care Leave Patients, Docs Frustrated

July 24, 2017 - Patients and healthcare providers are both struggling to overcome gaps in education, knowledge, and confidence about how to effective engage in chronic disease management, according to a new report by West.

Despite the health system’s growing reliance on population health management strategies to cope with an ongoing rise in chronic disease, adequate knowledge of how to care for long-term conditions such as diabetes and cardiovascular disease has not yet filtered down to individuals, the survey says.

Thirty-nine percent of patients stated that they only feel up to “somewhat knowledgeable” about how to effectively pursue their own chronic care, and close to 60 percent admit that they are probably not doing everything they should to manage their health.

“Coping with the challenges of chronic disease is hard for patients. Simply being diagnosed with a chronic condition can cause a great deal of stress, worry, and emotional pain,” says the report.

Approximately one-quarter of patients feel physically exhausted or angry after receiving a chronic disease diagnosis.  Around one in five feel anxious and frustrated.  For 23 percent of patients, these stresses can translate into sleepless nights, which could worsen their ability to complete self-care tasks and maintain emotional health.

READ MORE: 5 Ways to Turn Chronic Disease Management Knowledge into Action

“Wrestling with difficult emotions while also trying to manage symptoms and follow care instructions can be overwhelming,” West continues. “On top of that, patients lack a lot of the knowledge and confidence they need to successfully manage their conditions. The combination of these factors makes it easy to understand why patients are struggling to keep their chronic conditions in check.”

Part of the confusion and frustration stems from the fact that patients are generally unaware of the data that should accompany chronic care management. More than a third of respondents said they simply aren’t sure what their target numbers are for blood pressure, blood sugar, cholesterol, and weight.

Women are significantly more likely than men to state that they do not know what their health metrics currently are (51 percent to 34 percent) or what their goals should be (41 percent versus 28 percent). 

Female patients are also nearly twice as likely as males to report feeling stressed or anxious, although they are also much more likely to seek help when they feel their symptoms are getting out of control.

Interestingly, almost double the number of providers feel less than confident that their patients understand their health metrics.  Sixty-seven percent suspect that their chronic disease patients do not have a firm grasp on their current status and future health goals.

But providers are also strangely confident in their patients’ abilities to soldier on without them.  Two-thirds of providers said they believe patients can adequately manage their chronic conditions, revealing a striking disconnect – or perhaps a belief that patients don’t actually need hard numbers to stay healthy.

Yet seventy percent of patients believe that their providers aren’t giving them enough resources, education, and support to help them improve – especially at home and between the occasional check-up.

Forty percent of participants stated that they would like more support on an ongoing basis.  A third are eager for an individualized treatment plan to address their needs, and 31 percent believe they would benefit from more tools and advice about how to change unhealthy behaviors and improve their wellbeing.

Sixty percent added that they feel as if they spend more time discussing specific symptoms with their providers than learning how to manage their conditions and prevent acute issues from arising in the first place.

Patients are demanding more personalized information and a high-touch communication strategy, the survey revealed.  Seventy-five percent of participants want regular check-ins with their providers in between office visits – up to once a week for those recently hospitalized.

One in five patients believe they need 24-hour assistance, which may be best provided through mHealth applications and other patient engagement tools, to effectively manage their own care.

Just 21 percent of providers say they conduct regular and consistent check-ins with their high-needs populations.

“There are opportunities for providers to improve patient outcomes if they are willing to do more to engage patients with chronic conditions,” the report states.

“Expanding efforts to proactively reach patients where and when they need support can prevent some of the need for acute care. This is good for patients, and also for providers that earn reimbursements based on care quality.”

Providers have a number of options for improving the way they communicate with patients and monitor their health.  In addition to leveraging patient portals and other secure messaging tools, the Internet of Things is a promising development for monitoring and engagement.

Biometric monitoring devices, including home monitors and wearable devices, are capturing interest from patients. 

Half of respondents believe that one-way monitors, such as internet-connected blood pressure monitors or fitness trackers, can improve their chronic care.  Fifty-eight percent think two-way communication would be ideal, although these technologies are still in the early stages of development.

Quick and simple patient surveys can also provide significant benefits while ticking the boxes for personalized communications and treatment plans.  Providers can often use their existing automated appointment reminder systems to field short touch-tone phone surveys, which may ask patients to press one of their symptoms are under control and press two if they are not.

Even this basic information can help providers follow up appropriately with patients who feel as if they need a little more support or desire a check-in.

“When patients are engaged in their healthcare, results are better for both patients and the healthcare organizations that serve them. By working together with patients as partners, providers can more effectively manage chronic disease,” the report concludes.

“Successful chronic care produces the types of clinical outcomes that patients expect, and that healthcare providers need to thrive financially. It is in everyone’s best interest for providers to adopt chronic care solutions and patient engagement strategies that lead to active partnerships with patients and better clinical outcomes.”