Managing Chronic Conditions Through Care Coordination

Chronic disease management can be challenging for healthcare systems and clinicians to handle. Thankfully, new strategies for managing chronic conditions make it easier for clinicians to support patients, enable better outcomes, and drive long-term cost savings

Chronic disease is widespread — six in ten Americans live with one. More than 40% of Americans are living with two or more. Chronic disease can also affect patients of all ages. Providers who serve patients with chronic diseases have an opportunity to deploy Care Management strategies that enable patients to effectively manage their chronic conditions, improving patient outcomes, the patient experience, and the overall strain on the healthcare delivery system.

The impact of chronic disease can be costly from multiple perspectives: the financial costs are significant and continue to grow, clinician workloads are steadily increasing, and patients and families are experiencing poorer quality of life outcomes. Studies show that 86 cents of each dollar in healthcare can be tied to care for chronic conditions. These numbers only increase as many patients live with multiple chronic conditions — the cost of their care may increase by $2,000 for each additional chronic condition experienced.

Supporting patients living with chronic conditions requires effective management at both the individual and population levels. Well-implemented care coordination strategies have the potential to improve outcomes and reduce costs across the healthcare delivery system.

What is Chronic Care Management?

Chronic diseases are generally defined as serious mental or physical health conditions requiring ongoing medical attention lasting one year or more. They can include asthma, heart disease, depression, diabetes, chronic kidney disease, cancer, stroke, and substance misuse, among others. Chronic diseases are the leading causes of death in the United States and are also the primary drivers of increasing healthcare costs. Treatment for chronic diseases differs from treatment for acute healthcare conditions, which develop suddenly and typically last a short time. While acute healthcare conditions such as viruses or infections typically require a provider visit for treatment, care is generally complete once the condition has been resolved.

Patients with chronic illness receive ongoing medical care from their clinicians and care team to manage their condition and avoid future complications. Chronic Care Management is designed to provide appropriate care to improve chronic disease control, reduce the risk of hospitalizations, and improve the patient’s quality of life. It can be delivered by a multi-professional team and focuses on improving health outcomes.

Chronic Care Management is delivered over a longer time than treatment for acute care needs. Long-term care for chronic conditions typically provides patients with several care strategies managed by their team. For example, a patient living with diabetes might have a chronic Care Management plan that includes maintaining a blood glucose log, following a nutrition plan, taking medications as prescribed, and incorporating exercise into their lifestyle. For a patient with asthma, a chronic Care Management plan might include patient and family education, appropriate medications, home environmental assessments to reduce triggers, and ongoing assessments to measure disease impact.

What is care coordination?

Care coordination is key in the effective long-term management of chronic disease. Engaging all members of a patient’s care team — including the patient and family — clears the way for high-quality, high-value healthcare. Developing a plan of care that aligns with patient needs and preferences is a core care coordination principle. Care coordination strategies aim to reduce duplicative, unnecessary services and instead focus on personalized, patient-centered care.

Aligning a patient’s healthcare across multiple providers, organizing patient care activities, and sharing comprehensive information are essential for successful care coordination. Strong care coordination can result directly in improved healthcare outcomes, a better patient experience, and reduced healthcare costs.

Many patients may not be familiar with the exact definition of “care coordination”. Still, they can recount an experience with the healthcare system where they had a very positive — or very negative — experience tied to the coordination of care.

Well-executed care coordination results in better outcomes and reduces the risk of hospital readmissions as well as avoidable complications. Care coordination also goes a long way for patients and their families in restoring peace after a challenging healthcare event.

Examples of care coordination

Care coordination takes different forms. It’s patient-specific and tailored to the specific goals and desired outcomes for that individual. Broadly, all care coordination models include approaches that incorporate teamwork, data-sharing, and ongoing communication.

• Primary care coordination: Primary care coordination is often delivered through models such as patient-centered medical homes (PCMH). Primary care coordination is a model that focuses on partnership with patients and their families, coordination across multidisciplinary care teams, and healthcare interventions tied to specific patient needs and concerns.
• Acute care coordination: Acute care coordination typically focuses on transitions of care, such as a discharge from a hospital back to the home. The care coordinator ensures patients have scheduled follow-up visits, filled prescriptions at their local pharmacy, and that the patient or their family received appropriate education and instructions for care.
• Long-term care coordination: Long-term care coordination most often focuses on patients living with chronic conditions. A plan of care is established among clinicians to ensure patient goals and outcomes align with treatment. Care coordination is also deployed to support a patient with medical and lifestyle interventions, including prescription medications, patient and family education support, and connections to community resources.

How chronic care coordination can help patient outcomes

Care coordination is generally understood as an essential tool for healthcare teams and systems focused on delivering high-quality, high-value care. Successfully deploying care coordination strategies can result in significant outcomes, as outlined below.

Eliminate disjointed care

Care coordination reduces inefficiencies in healthcare. With coordinated care, patients are less likely to experience siloed care from providers who are out of sync. Disjointed care can result in duplicative testing and treatment, confusion for patients and their families, and poorer outcomes overall. Coordinated care strategies eliminate these challenges.

Provide seamless care

By sharing comprehensive patient information across clinical teams, patients are more likely to have a seamless care experience. When all providers on a team have the same picture of the patient they are treating, the patient and their family are able to navigate the healthcare system more easily and feel assured that the patient’s goals and preferences are driving the plan of care.

Increase patient outcome and satisfaction

With the elimination of disjointed care and the improvement of a seamless patient experience, patient outcomes and satisfaction increase. Coordinated care allows providers to work together across a team to align care interventions and improve patient outcomes. Patients and families who experience a coordinated team approach have a better overall experience, resulting in improved patient satisfaction.

Decrease costs for patients

Care coordination is known to reduce costs for the healthcare delivery system and patients. With coordinated care, patients are less likely to experience complications and the accompanying costs that ensue. Additionally, strategies in care coordination such as medication management can reduce out-of-pocket costs for patients and their families. This reduction of costs at the individual level also supports increased patient satisfaction.

What you’ll need to successfully manage chronic conditions through care coordination

Managing chronic care involves the right staff and the right technology; without either, offering successful care coordination can be difficult. Implementing care coordination strategies is more important now than it has ever been.

Government payers and health insurance plans are increasing requirements around population health strategies and value-based care. Clinicians and healthcare systems need to identify strategies to align with these programs, and care coordination offers an opportunity to achieve program objectives such as better health outcomes and reduced healthcare costs.

That said, care coordination across multiple patients can be a balancing act. Clinicians and health systems need a Care Management platform like Welkin to manage care coordination and improve patient outcomes effectively. Welkin offers a superior platform that allows care teams to create multiple seamless care coordination programs.

Learn how a Care Management platform like Welkin can help you provide better care coordination for patients with chronic conditions.