A patient’s chronic illness journey is cyclical and complex. It's not a linear path but a continuous loop of pre-service, service, and post-service interactions with the healthcare system. Without adequate self-management, health literacy, and personal discipline, a patient’s health can deteriorate, and their condition worsens significantly.
For high- or rising-risk patients diagnosed with one or more chronic diseases, care management offers six primary benefits:
- Personalized care planning
- Individualized goal setting
- Support and education for consistent, positive action
- Advocacy and access to resources and community services
- Coordinated care among specialists, other providers and services
- Ongoing oversight, engagement, and encouragement
When care management is delivered via ThoroughCare, care managers and clinical teams can more easily implement patient-centric care coordination.
Built upon clinical standards and evidence-based research, ThoroughCare provides all the tools and structure to deliver an effective, efficient, and profitable care management program.
Extending care management value throughout the patient’s journey
Care teams have a unique opportunity to enhance care management’s value—to the patient and the healthcare enterprise—by understanding the broader chronic disease journey.
Figure 1: Common stages in a patient's chronic disease journey.
As shown in Figure 1, the patient’s health journey tends to go through phases.
Care management can be introduced at the point when a clinician sees that a patient:
- Has been diagnosed with one or more chronic conditions
- That will persist for at least 12 months or until the patient’s death
These chronic conditions include, but are not limited to, Alzheimer’s disease, arthritis, asthma, cancer, chronic obstructive pulmonary disease (COPD), diabetes, heart disease, hypertension, osteoporosis, and more.
At critical points in the chronic disease journey, care management services can have a measurable impact, including:
- Educate patients on their disease(s), treatment, and medications
- Support patients to follow their treatment plan
- Help patients set realistic and achievable goals that are personally motivating
- Avoid worrisome exacerbations
- Slow or reverse disease progression
- Prevent hospitalization
- Intervene before needing emergency services
- Enhance patient self-management and decision-making
- Improve quality of life
Key moments in a health journey with chronic illness
Figure 1 highlights a patient's health journey with a chronic illness, which typically includes several key moments and stages, and demonstrates the moments when a Principal or Chronic Care Management (CCM) program could be considered.
When designing a CCM program, care teams can use this patient journey to consider the real-world experiences, emotions, and practical struggles patients face throughout the cycle.
With this awareness, clinicians and care managers can quickly engage patients in context and build trust, engagement, and cooperation.
Build a Chronic Care Management program in context of the patient’s health journey
Figure 2 focuses on those moments in the cycle where care management plays a critical role.
Figure 2: Moments when a Chronic Care Management program plays a critical role in a patient’s health journey.
At each point in the cycle, consider the following questions when designing a CCM program. They will enable the team to create tailored support that meets each patient in their current season of living with chronic illness.
Ask questions to tailor support for the patient’s care journey
Phase 1, Primary care or specialist diagnosis: The patient visits a primary care provider to discuss symptoms. The provider may make a preliminary diagnosis or refer the patient to a specialist. The patient sees a specialist for further evaluation and testing. The patient receives a formal diagnosis of a chronic illness.
Start care management early: Depending on the patient’s clinical picture and status at the time of diagnosis, enrolling in a care management program at the moment of diagnosis may be appropriate. This is particularly important if the new condition compounds an existing chronic illness.
Questions to consider:
- Will this patient be able to self-manage with this new diagnosis?
- Do they have adequate resources (physical, cognitive, social ) to support them in their journey?
- What might they struggle with initially that could derail their initial treatment plan?
- If they qualify, what high-value benefits could care management support provide?
Phases 2 & 4, Treatment planning and chronic disease management: At points 2 and 4 in the cycle, the healthcare team discusses treatment options with the patient and develops an initial treatment plan, which may include medication, lifestyle changes, therapy, or surgeries. That care plan will be revisited as part of ongoing disease management.
Kick-off care management with the initial treatment plan: At this time, the provider may see that the patient is at high risk for exacerbations or needs extra support to implement the treatment plan. Enrolling the patient in care management now could provide the structure, education, and engagement required to help the patient curb disease progression.
Questions to consider:
- Does it seem that the patient understands and can take action on the new treatment plan?
- Could medication access, management, and adherence be challenging for this patient?
- Can this patient embark reasonably well with the behavioral changes that are needed?
- If they qualify, what high-value benefits could care management support provide?
Phases 3 & 5, Flare-ups, complications, and disease progress: Cycling between points 3 and 5 could include acute episodes and periods when the condition worsens or the patient experiences new flare-ups and complications.
At these points in the journey, the patient seeks emergency medical attention, could be admitted to the hospital, or needs to recover from acute episodes, which may require minor or major adjustments to the treatment plan.
Introduce care management when risk increases: When the patient experiences their first acute episode or complication from their chronic illness, they may require temporary oversight—through a Transitional Care Management program—or they may need ongoing and regular support provided through Chronic Care Management. Now, care coordination and having a dedicated care manager can help to lessen the need for acute care and prevent future exacerbations that lead to disease progression.
Questions to consider:
- What type of support does the patient need now—education, motivational support, help with self-management, or community resources?
- Because of this flare-up or complication, what changes will the patient need help making?
- What are the most important areas to focus on in preventing a future complication?
- If they qualify, what high-value benefits could care management support provide?
Advance Care Planning (ACP): While not shown in Figure 2, the patient journey should include Advance Care Planning (ACP) if their chronic illness has become life-limiting. ACP can be seamlessly integrated into CCM at any time. An advanced directive provides the patient, their family, and the care team guidance on the patient’s preferences if they cannot make healthcare decisions for themselves.
End-of-Life Care: If or when a chronic illness becomes terminal, the care team may transition the patient out of CCM and into palliative or hospice . With palliative care, the focus shifts to relieving symptoms and improving quality of life. In hospice care, the focus shifts to comprehensive care for managing pain and symptoms nearing the end of life.
ThoroughCare supports the patient’s journey
Provider organizations can capitalize on the features and functions ThoroughCare offers for standardized, evidence-based care management services.
From seamless program implementation, enrollment, and onboarding to care planning and task management that fits easily into the clinical workflow, ThoroughCare enables efficient, effective care coordination revenue streams.
The platform, supported by powerful analytics and robust dashboards, reports, and time logging, streamlines care coordination and maximizes each team member’s contribution to patient care.
