It is no secret that chronic disease is costly for healthcare providers. Hospital readmissions are often related to chronic health complications and estimated to cost hospitals $528 million in Medicare penalties for the 2017 fiscal year alone. Chronic disease management is also often complicated, and requires both provider and patient have a firm grasp on multiple concurrent treatment protocols.

Although chronic disease management is on the rise, more care improvements are still needed. Patients are struggling to manage their conditions on their own, resulting in poor outcomes for both the health of the patient and bottom line for healthcare systems. Research shows many chronic patients are willing to learn and want to improve their quality of life; however, in many cases, they simply lack confidence in their understanding of how to make decisions or changes that will create real improvement. And patients who feel less knowledgeable about managing their chronic condition are more than three times as likely to rate their ability to manage their condition as fair or poor.

Results from a recent West survey on chronic disease management found that 59% of patients with chronic illnesses feel that they could be doing more to manage their condition and a staggering 20% rate their ability to manage their condition as poor. In addition, 67% of providers believe patients are unsure about their target metrics.

Both patients and providers agree that there is a dire need for improvement when it comes to chronic disease management, and this lack of patient confidence signals there is a specific need for more intra-visit support. Patients who are not knowledgeable about their metrics and how to manage their conditions are more likely to experience costly hospitalizations and declining health and drive readmission penalties. When it comes to chronic disease management, post-discharge and intra-visit communications can help provide support to patients struggling to adhere to treatment guidelines.

Web-enabled surveys as a CDM tool

Effective chronic disease management can lead to better clinical outcomes that positively impact hospital and health organizations’ success rates, reputation and bottom line. The idea that providers need to offer more support outside of the hospital or clinic is a sentiment echoed by patients who want to see healthcare teams expand long-term support efforts. For example, Medicare’s HCAHPS (Hospital Consumer Assessment of Healthcare Providers and Systems) surveys show that patients often feel disconnected from their medical team after discharge. In fact, recent HCAHPS data reveals half of surveyed patients reported feeling confused or uncertain about how to comply with care instructions after being discharged.

Following the same concept of HCAHPS surveys, clinicians can take this a step further by incorporating their own surveys using web-enabled technology. Surveying chronic patients allows medical teams the ability to gauge a patient’s health status while outside of the clinical setting, escalate cases where patients are at risk and intervene before reaching the point of needing acute care. For example, using automated technology, a provider might send a brief online or touch tone survey to their chronic patients. The survey check-in might ask them a short series of questions to gauge pain levels, symptoms, energy levels or sleep patterns. Based on the survey answers, the healthcare team might follow up with the patient or recommend they schedule an office visit if their condition has deteriorated.

Surveys are currently underutilized by most providers as a chronic disease management tool. Although many providers already have automated reminder technology in place, they may not be harnessing its full capabilities to deliver surveys and expand monitoring efforts for their chronic patients.

When providers were asked how they monitor the health of their chronic patients, 42%  indicated they ask questions during in-person visits, 27% reported they have other staff check in with patients outside of the clinical setting and only 5% stated they use survey check-ins that ask questions specifically about treatment plans. The current approach not only delivers poor results in terms of accurately monitoring each patient’s individual health status, but can prove costly when considering the staffing requirements.

Connected health improves chronic care

Healthcare providers are often faced with the difficulty of treating patients with multiple chronic conditions that require a substantial amount of support. They are also acutely aware that a majority of disease management occurs outside of the clinical setting and many patients are struggling to make the needed lifestyle adjustments required. Clinicians can adopt technologies that help them connect with patients throughout their treatment journeys in a cost-effective way. Here is an example:

A recently discharged patient dealing with diabetes complications has been directed to follow up with his primary care physician for close monitoring. Using a blood glucose meter and a heart rate monitor, the physician is able to closely monitor the patient’s health status while he is recovering in his own home. In addition to collecting daily analytics on his physical health, the clinician can also create and schedule a series of automated communications that support the patient’s long-term recovery plan including notifications via email or text when it is time to take medications, schedule routine eye and extremity exams, or make an appointment for an A1c draw. At any point, if the patient’s vitals indicate signs of distress, treatment is either not being adhered to or there is a risk of complications, the medical team can then intervene to make sure the patient receives support before experiencing an adverse health event that sends him back to the hospital.

The previous example highlights some of the advantages of using remote biometric monitoring technology with automated support in post-discharge treatment plans. It also shows how care teams can establish critical touch points on when to intervene, and use monitoring devices to make informed decisions when predicting negative outcomes that may result in a readmission.

The office visit is just the beginning of care – it’s no longer enough to solve the complicated treatment issues involved with chronic disease management. Technologies that enable patients to stay connected with their doctors on a day-to-day basis, and provide clinicians with data, are changing the way doctors and patients approach chronic disease management. The key is for healthcare providers to take advantage of the capabilities of existing technology, review real-time patient data, and respond appropriately.

About the Author

Chuck Hayes is an advocate for utilizing technology-enabled communications to engage and activate patients beyond the clinical setting. He leads product and solution strategy for West Corp.’s TeleVox Solutions, focusing on working with healthcare organizations of all sizes to better understand how they can leverage technology to solve organizational challenges and goals, improve patient experience, increase engagement and reduce the cost of care.