Because of the complexity of chronic disease, population health leaders often struggle to find scalable management approaches that improve outcomes and manage utilization. Our survey of chronic disease management programs identified common design flaws that lead to ineffective patient management and unmanaged costs.

First, programs often narrowly focus on treating disease in a short-term window (e.g., the 30-day period post-discharge) and miss opportunities to prevent disease and escalation outside those parameters. In addition, providers often overly-segment programs by disease state, leading to gaps in care and unnecessary duplication of resources. Finally, programs may not set clear guidelines for when patients should access high-cost services (e.g., remote patient monitoring, intensive nurse-led care management) leading to inefficient resource use.

This research report offers three recommendations for developing a scalable chronic disease management program.