How digital tech can aid care for patients with chronic conditions

Four emerging capabilities can fill in the gaps between in-person visits, which is crucial to monitoring care regimens and ensuring issues are identified early on.

Digital platforms that help communicate with patients can connect them with resources to better manage chronic health conditions.

Chronic conditions are becoming more of a concern for patients and the healthcare organizations that aim to manage their conditions. According to the CDC, six in 10 adults in the United States have a chronic condition, and four in 10 have two or more such health concerns.

As that number continues to grow across the United States, it is creating significant challenges for all concerned. On average, one in 20 people qualify as high-risk for poor health and high service usage because of the complexity of their health conditions and co-morbidities. This increases overall costs for healthcare systems, adds strain to already overburdened care teams and negatively affects the quality of life for millions of people.

In light of this data, it’s clear that the traditional self-management approach to chronic care management isn’t effective. Healthcare needs a new digital strategy to lower barriers to care, identify gaps in care, slow disease progression and provide the added support that patients need — not just during infrequent clinic visits, but as they live their everyday lives.  

Leveraging digital technology

Relying on a manual chronic care management approach presents significant challenges for healthcare providers who have limited time and resources. Adding automated digital solutions to identify patients who need added support and deliver care beyond the clinic can help patients keep track of their care plan, reduce the burden on the care team, improve chronic care management efforts and help organizations succeed in value-based care.

This technology-driven approach can support a more sustainable and effective solution for several reasons.

Scalability. Dedicating a member of the care team to regularly monitor patients with chronic conditions and identify those who may be at risk for developing one isn’t feasible. However, with digital communication pathways, such as this one, care teams can monitor, educate and coach patients to keep them on track with their care plan without adding to care team workload. This type of automated and optimized patient engagement can improve outcomes across a range of chronic conditions, including hypertension, diabetes and congestive heart failure via simple text-based communication.  

Identifying care gaps. A technology-based solution, such as this one can help bridge gaps in care that, if ignored, may lead to disease progression or other poor outcomes. Identifying gaps, like missed routine screenings and health data related to chronic conditions, or risk of chronic conditions, is essential to keep patients as healthy as possible. Using information integrated with their electronic health records system, providers can streamline pre-visit planning and close gaps at the point of care where it’s most impactful. Patients receive more complete care and benefit from more efficient, well-planned visits. 

Personalized patient communication. A care plan to manage a chronic condition can be confusing for patients. If they have more than one chronic condition, keeping track of medications and lifestyle modifications can be overwhelming, especially if they face challenges like poor health literacy or language barriers. If patients do not understand their care plan or can’t follow it for any reason, there’s a higher risk of noncompliance and worsening health. Simple text-based communication pathways can engage patients at every step. Using easy-to-understand language and prompts can assist patients in reporting issues or barriers so care teams can intervene. When patients can engage on their own terms and revisit resources and information whenever they want, they are empowered for success.  

Remote patient monitoring. Healthcare tends to be episodic, so in-person visits can be separated by weeks, months or even longer gaps. In addition, interactions with healthcare providers are also becoming shorter, making it challenging to accurately diagnose a condition, adjust treatments or address barriers patients face in their day-to-day lives. Remote patient monitoring is a valuable tool that improves connectivity between patients and care teams and provides more comprehensive oversight of the patient’s health and lifestyle habits.

Choosing a strategy

As chronic diseases become more widespread, resources more strained and social determinants of health continue to negatively impact some populations, it’s more important to stay closely connected to patients between visits and deliver proactive chronic care management.

Patients with chronic conditions may have different physical needs and comfort levels that make it difficult for them to follow their care plan and manage their health. Digital technology can give patients an easier way to access care and stay engaged, help care teams identify gaps in care, and enable healthcare organizations to deliver very high-quality care to every patient.

Health Catalyst Editors is a team of senior editors and writers at Health Catalyst offering experience and broad knowledge of the industry.

This blog, written by Health Catalyst, previously appeared here.

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