The Executive Suite: Delivering Optimal Chronic Disease Care

Thursday, October 13, 2022

Delivering Optimal Chronic Disease Care

Providing chronically ill patients the attention they need to manage their medical conditions is a long standing challenge for physician practices. Clinicians and their care teams lack the time and resources to manage chronic diseases optimally.

The challenges physician practices face in providing excellent chronic care fall into two main categories:

Lack of diagnostic data: Diagnostic readings should be taken more often than at in-office appointments (PDF) to build a true picture of the patient’s condition and needs. Taking more in-office readings is not an optimal solution to this data problem. More visits may stress facility capacity and workforce availability, and increase the burden on chronically ill patients and their caregivers, who are estimated to spend two hours a day or more on health-related activities.

Managing complex care: Chronically ill patients require longer appointments with their primary care provider (PCP) and often need care from multiple specialists. They need significant help managing medications, appointments, and testing. PCPs excel at providing the holistic view of these patients’ health, particularly if they are complemented by specialist expertise for chronic conditions such as chronic heart failure, kidney failure and hypertension.
A blended approach

The emergence of a wide range of virtual care providers offers physician practices a way to improve the care they deliver and coordinate for patients managing chronic diseases. Traditional and virtual care providers must form partnerships to better serve patients with chronic diseases by blending all the modes of care available—in-person and virtual, in-office and at home, synchronous and asynchronous—to provide optimal care.

This approach is based on research that shows a multi-disciplinary, team-based approach with more regular monitoring improves outcomes and costs for hypertension patients.

At a high level, this blended approach combines three elements:

Integrating PCPs with specialized care management teams provides patients with both the focused care they need and a PCP with a holistic view of their health.

At-home diagnostic readings, taken regularly and relayed to clinicians electronically, enable providers to intervene sooner when a patient’s condition is changing and build a more robust long-term picture of the patient.

Bringing specialty care to the patient’s home, whether in-person or virtually, eliminates transportation issues, frees up caregivers and provides the support patients need to stay on their care plan and avoid complications.

Traditional and virtual care providers need to build trust with each other to provide the coordinated, wrap-around care that chronically ill patients need.

To succeed, virtual care providers must view traditional physician practices as invaluable partners in patient care. They should strive to develop customized relationships with them that meet the needs of their clinicians and their patient populations. Traditional practices must also embrace collaborations with virtual care partners who can complement the difficult work of caring for chronically ill patients. Only by working in concert can we deliver the care these patients need and deserve.