New Tools Can Improve Chronic Care Treatment, But Half-Measures Won't Work

By Charlotte Hovet, MD, MMM, Medical Director, Dell Healthcare Services

Caring for patients with chronic diseases can be painful for physicians, both professionally and personally. Not because of the patients themselves, but because for the last 40 years, despite new and better medications and enormous monetary expenditures, we haven’t been able to make an appreciable difference in outcomes. That’s because the real impact on chronic care happens outside the clinic and the hospital. The lifestyle choices patients make, not the treatments we offer, determine the course of these diseases. And while we’ve tried to educate our patients on the lifestyle choices they need to make, we haven’t really helped them do it.

At best, we have helped our patients delay serious complications. At worst, we’ve watched our patients slide downward, helping them cope with each crisis but unable to prevent the next. On a professional level, it’s frustrating. On a personal level, it’s painful. We see these patients often and we grow to like and even love them. Often, we are witness to incredible courage and good nature in the face of immense suffering. We ache for them and their families.

And for those patients and families, it’s even harder. We can walk away at the end of the day, but they can’t. These diseases permeate every part of their lives, destroying health, creating disability, devastating family finances and robbing children of their parents too soon.

On top of all that, physicians’ financial stability will soon be in jeopardy if we can’t change the chronic care picture. New payment models put us squarely at financial risk for containing and reducing the cost of care. And the only way to really cut costs is to prevent the complications that drive costs up – those that require hospitalization and other very expensive therapies, like dialysis.

Technology Can Help Us Turn The Tide

Now for some good news. Telehealth technology, remote biometric monitoring, health coaching, and patient engagement are proving to be powerful tools in the fight to improve chronic care outcomes. Now, we (or other caregivers on our team) can be there with our patients at the moment of choice: at 9 a.m. in the office, when everyone else is diving into the box of donuts provided by a well-meaning and benevolent boss; at the end of the day, when a patient is stressed from work and a bad commute and must choose between exercise, family obligations and the longing to plop down in front of the TV with a beer and a bag of chips. We can be there in the morning to remind them to take their medications. We can be there to warn them of air quality issues that can make their asthma worse. We can see their weight rise and alert them that their congestive heart failure may be worsening. We can see their blood sugar levels and congratulate them on that walk they took that made the difference.  In short, telehealth gives us the power to be there for our patients when they need us the most – at home, in the office, and throughout their days.

That is a power we have needed, and our patients have needed the support we can now offer. To change the course of chronic disease, patients have to remake their lives. Diets, exercise habits, medication routines – they all intrude on the lives that patients want to lead. What patients need most is on-the-spot support: medication reminders; immediate access to answers and information; dietary guidance in the face of temptation; exercise suggestions; and most of all, an ongoing connection with a coach who cares about them.

Building A Chronic Care Model That Works For You And Your Patients
So how do you, as a physician, use these tools to build a system that will help you succeed in turning the tide on chronic disease? First, recognize that half-measures and surface changes probably won’t pay off. To ensure that you and your patients really succeed, you need a comprehensive program that uses all the new tools available.

The good news is that it doesn’t have to be hard, and the financial savings from better outcomes can offset the costs. Here, in brief, is a basic plan for effective chronic disease management:

1. Negotiate contracts that build in funds for effective care. Make sure that health plans aren’t the only ones that reap the rewards from your good work. Most health plans recognize the value of comprehensive chronic care and telehealth technology and are willing to invest it.
2. Use analytics to identify patients with chronic disease or who are at risk for a chronic disease. Population health analytics are widely available now, and if you are part of an outcomes-based contract model or ACO, you should have access to this data, either through your hospital partners or through the health plan. If you are assigned a patient population through your contract, you may have patients you haven’t even seen yet who could cost you dearly. So identifying those at risk is a crucial step for your sake as well as theirs.
3. Engage your patients. Reach out proactively to patients who need your help. If you are responsible for patients who are at risk, don’t wait for them to come to you. Contact them by letter, email, phone, text or whatever means you have available to let them know you are ready to care for them and have important resources to help them. And don’t forget your healthy patients. Use your patient portal to provide access to reliable information to answer your patients’ most common questions and you’ll spend less time during exams re-educating those whose information is erroneous.
4. Be as mobile as your patients are. Your patients are more likely to engage with your portal on their smartphone or tablet than on a computer. Make it easy for them. It’s not difficult or expensive to create a good portal app that facilitates patient engagement. For all your patients under 30 (and a good many of those over 30), a text message is the preferred communication medium, and they are more likely to respond to a text than to a phone call. Set up your systems to allow a choice – voice reminder or text reminder for appointments and other important updates.
5. Tap into population health management resources. A small study done in 2014 by Health Net Connect found that the combination of remote monitoring (via the Internet of Things) and videoconference health coaching made a powerful difference in outcomes for patients with congestive heart failure, far more than remote monitoring and usual communications. The immediacy of telehealth helped patients better understand their disease and to connect their symptoms and biometrics with their daily choices and prognosis. Work with your hospital and health plan partners to take advantage of their efforts in population health management. A good program will offer telehealth videoconferencing and remote monitoring capabilities, coaching, automated text messages, a social media outreach and education program, social media listening and analytics for monitoring and reacting to changes in patient wellbeing.
6. Use your patient portal to enhance communication with all your patients. Make sure your portal is more than a static billboard. It’s relatively easy now to build in communication tools, such as secure email, that increase communication. Your portal should also give patients access to their health records and the ability to correct information if they see an error.
7. Use social media to share health information. First, learn the nuances of social media engagement. Then set up a social media presence and use it to share health information (but never personal information about you or your patients). For example, you could post links to interesting articles, healthy recipes, exercise advice and new research findings you think might be useful. And your patients can comment on your posts, giving you another opportunity to engage them in taking care of their health. You’ll learn more about them, while they learn more about how to stay healthy.

If we can put these tools to work for our patients, we may be the first generation of physicians who make a real difference in chronic disease outcomes. For those of us who have spent decades despairing for our patients with diabetes, heart failure, asthma, high blood pressure and other chronic conditions, that would mean a lot. In fact, that would mean everything.