How Physicians Can Provide Better Care for Patients with Chronic Conditions

It's well documented that the bulk of patient health outcomes are impacted by factors outside of clinical care, ranging from diet to education to housing. It would seem obvious, then, that quality care between doctor visits is vital for achieving better health outcomes, particularly when it comes to chronically ill patients and those in underserved communities.

Yet providers typically don't have the infrastructure necessary to maintain consistent insight into the patient's life and health outside of clinical interactions. And even though most doctors only see patients during brief clinical checkups, they own 100% of the responsibility for the outcomes. Further, there is a gaping hole in the industry's care delivery model, leaving both patients and physicians at a loss.

Two huge challenges exist: one related to patients, the other related to providers. First, the volume of people with chronic disease – and particularly more than one – is growing fast. So is the number of people aging into Medicare. One in four American adults and 66% of Medicare beneficiaries now have multiple chronic conditions. And the Medicare population increases by 1.5 million people annually.

At the same time, fewer primary care providers are available to take care of this growing population, an issue compounded by more clinicians leaving the field. These factors have created a situation that’s overwhelming the health care system.

Helping providers effectively and sustainably treat the 117 million Americans with chronic diseases requires:

• More trusted, empathetic support for patients between office visits,
• Reaching and educating a patient population neglected and frustrated by a complex, confusing and overburdened health care system; and
• Better enabling patients to manage and improve their conditions at home

So how can a busy physician maintain visibility into a patient's health once they leave the clinic? They need infrastructure to support chronic care management (CCM), which includes a software platform designed to help teams and patients manage medical conditions and treatment plans more efficiently, and an experienced team to interact with patients.

CCM solutions vary in capabilities, and there are many considerations to keep in mind. Foremost, providers need to examine their capabilities.

While they could integrate and manage a CCM system themselves, doing so would require a significant amount of capital and additional staff. As a rule of thumb, for every 200 patients, a practice needs to add three employees to a chronic care team. It’s unlikely that physicians who are struggling just to meet with patients for 20 minutes, then document the visit, would find the time to oversee and fund an infrastructure that reaches beyond the clinic’s doors.

What’s needed to address this situation is a combination of scalable CCM services and technology that physicians, health systems and payers that can use to identify rising-risk and chronically ill patients, while managing their health. That requires technology-driven, personalized intervention by experienced and empathetic care navigators.

Many non-clinical factors, such as transportation for office visits or food insecurity dramatically shape health equity and overall patient health. Unfortunately, our health care system isn’t designed to help physicians deliver personalized, hands-on attention when a patient leaves the office. What’s more, screening for social factors isn’t practical when treating thousands of patients.

As for patients, overcoming health obstacles can feel unachievable, especially in situations where they must choose between putting food on the table or buying medication. Additionally, some of those who suffer from chronic disease might also be caregivers for elderly or sick family members. So while losing 20 pounds might seem reasonable for one patient, it may seem unattainable to a patient who already lacks the resources to get to a gym or buy and prepare healthier food.

Care navigators can make targets are more achievable. With proper coaching, small steps can add up to real progress. A walk to the end of the driveway can quickly turn into a stroll around the block. Further, care navigators can find resources chronic care patients might not otherwise know about, whether it’s lower-cost pharmacies or a nearby food bank. Help like this fills in the gaps between office visits while demonstrating empathy and building trust with patients.

Combining trained care navigators with new technology can help clinicians spend more time with significantly more patients, while creating a more complete picture of patient health and barriers to care.

Today there are tools that can deliver actionable data insights from EHRs to care navigators so they can provide the right services to the right patients at the right time. And with automated billing integrated into EHRs, practices can bill more and treat more without adding steps to their daily workflow.

Vendors that combine their technology with specifically trained care navigators can help eliminate the need for office staff and clinicians to learn new workflows, hire and train employees, and absorb additional costs such as salaries. And interacting with trusted care navigators can help patients become more engaged and committed to improving their health.

Are we asking physicians to do too much these days? Perhaps. But thankfully, there are new tools to help them better reach and serve the ever-growing number of patients with chronic conditions.

Ferry is president and CEO of Engooden Health, a provider of scalable chronic care management (CCM) services and technology for physicians, health systems, and payers to identify rising-risk and chronically ill patients and positively impact their health trajectories.