Care Transformation Center Blog

Here's why you're behind in chronic disease management

by Darby Sullivan and Tomi Ogundimu

Chronic disease care currently accounts for $1 trillion in spending across the United States. By 2030, the number of patients with three or more chronic diseases will nearly triple to 83.4 million. Can your chronic disease management program accommodate three times as many patients? Too often we find that providers rely on technology innovations to solve the challenge of scale. But there's no magic bullet to supporting successful self-management.

Optimize CHF Management across the Continuum

Common errors

Most providers make at least one of these common errors when making investments in chronic disease management:

  • Overly segment services into disease-specific models. All key stakeholders in the industry understand the evidence base behind disease management programs. But few have built a centralized structure to meet the needs of comorbid patients.

  • Narrowly focus on short-term goals. The Affordable Care Act designed policies to incentivize provider organizations to ensure patients remain healthy post-discharge. But providers remain too focused on the first 30 days, rather than long-term stabilization.

  • Indiscriminately offer access to high-cost services. The majority of population health departments now stratify patients based on risk. But not all consider psychosocial risk factors in their algorithms or separate out services for rising-risk patients.

3 steps to scale services

To avoid these pitfalls that result in inefficient resource utilization, review these three imperatives for scaling services:

  1. Find modifiable patient risk factors. Most organizations already conduct root cause analyses to determine utilization trends of acute patients. In addition, invest in proactive identification strategies to locate and engage disconnected patients. This data can inform programmatic investment decisions. But rather than segment programs by disease, align services to modifiable risk factors agnostic of chronic condition. Tailor care planning using clinical and non-clinical indicators.

  2. Anchor consistent, long-term services in ambulatory care. Assign dedicated support for patients coming from the hospital, ED, or post-acute care to manage the transition. Once patients are situated in primary care, the care team must offer self-management support, provide medication support, address psychosocial needs, use telehealth, and connect patients with advanced illness care. Tier intervention options based on patient acuity, matching more costly and time-intensive options to higher-risk patients.

  3. Set clear pathways to specialists. PCPs don't always know when patients can be managed in primary care or when they should be referred to specialty care. Offer decision support with hardwired coordination pathways, including real-time specialty consults and care compacts, to ensure seamless transitions and avoid acute utilization.
 

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