There is a “perfect storm” facing health care today: the spread of chronic diseases, physician shortages, and an aging population on Medicare that will overwhelm our health care system if action is not taken. More than 133 million Americans have at least one chronic disease, and as the number continues to grow, providing adequate care for these patients has never been more challenging. It is widely recognized that factors outside the clinic primarily influence health. However, there is an expectation that providers should bear all patient outcomes, even if only seen during brief clinical visits.
Social determinants of health (SDOH) such as socioeconomic status, nutrition, access to transportation, and status of care often influence patient outcomes more than clinical care. While social, economic, and environmental factors influence patient health, providers can do more to meet patient needs. Personalized services to help patients take medications or organize transportation to outpatient care, there is a huge opportunity to improve health care and provide patients with more honest and compassionate support between office visits.
Closing care gaps
Unfortunately, most providers lack the appropriate infrastructure or resources to maintain a consistent understanding of their patients’ lives and health beyond clinical interactions, leaving a gap in the healthcare industry’s primary care delivery model. Close this gap by equipping healthcare professionals with technology and human resources to provide ongoing communication with patients through direct and consistent communication to gain insights that are difficult to understand during a short office visit.
The Centers for Medicare and Medicaid Services (CMS) sees an opportunity to expand care between office visits. This year, CMS doubled down on efforts to support chronically ill patients, increasing chronic care payments by 51 percent. Adding value to traditional fee-for-service and federally qualified health center (FQHC) models gives chronic disease management (CDM) providers the opportunity to unlock new revenue streams while promoting services that deliver the care patients need. They need it.
Creating a custom CDM
CMS hopes that increasing funds can motivate health care providers to implement chronic care management (CCM) into their practices. More than 50% of American adults have at least one chronic disease, which means that every primary care provider has many patients who can benefit from CCM. Given the volume of chronic disease patients, successfully establishing and expanding a CDM program that accurately meets the needs of the population requires adequate manpower and technology to help demonstrate and prioritize valuable insights.
Chronically ill patients need person-centered care coordination that goes beyond physical contact in the clinic. A successful CDM involves phone calls to patients, correspondence with care teams, conversations with pharmacies, food banks and transportation providers, projects that are not sustainable at scale for a primary care practice.
Labor shortages and increased patient cases make building a robust CDM program challenging. To overcome these operational challenges and take advantage of CMS incentives, many providers have dedicated CDM to technology solutions and professional care staff necessary to meet the unique needs of critically ill patients.
The spectrum of tech-driven care
Scalable CDM requires marrying technology with the right profile of healthcare professionals. Automation and technology help streamline many aspects of healthcare today, but no amount of technology can replace the impact of relationships and human interactions on patients’ health outcomes. It takes the best of both worlds to move the needle.
When a CDM program marries intelligent technology with professional care providers, the benefits are clear, including:
– Improved disease detectionTechnology that analyzes electronic health records (EHR) can detect and detect chronic conditions that may otherwise go unnoticed. Providers can better care for more eligible patients and take advantage of CMS incentives.
– Improved patient health knowledge; The best chronic disease management programs emphasize patient education. People with chronic illnesses increasingly need guidance and practical day-to-day solutions to self-manage their condition. CMS-required monthly check-in calls allow caregivers to share health information and best practices on an ongoing basis, furthering a patient’s health goals.
– More fair careCDM, naturally, should break down the barriers that prevent patients from getting the care they need. Because providers have historically lacked insight into a patient’s life outside the clinic, they are often unaware of conditions at home that can impede a patient’s progress, such as the inability to afford prescriptions or lack of transportation to doctor’s appointments. CDM is an opportunity for providers to better understand and understand patient behaviors at home to remove clinical and non-clinical barriers to health and ultimately help patients overcome inequities.
Lead with passion
Chronic disease management programs are a great opportunity for health care providers. They create opportunities to introduce new revenue streams while providing better and more consistent care for patients who need it most. Of course, no chronic disease management program gets off the ground without patient buy-in. Closing care gaps is only possible when patients trust the people they care for. All the technological solutions in the world don’t amount to much without genuine compassion and a desire to help patients improve their health. A successful CDM program promotes a new level of care that all patients deserve.
About Thomas Ferry
Thomas Ferry is president and CEO of Ingoden Health, a provider of scalable chronic care management (CCM) services and technology for physicians, health systems and payers to identify growing and chronically ill patients and positively impact their health lifestyles. Prior to Engoden, for nearly 20 years, he was the CEO of Kuraspan, a release planning technology company that he co-founded in 1999 and sold in 2016.
