People are living longer but sicker due to chronic illness. The Centers for Disease Control and Prevention (CDC) determined that seven chronic diseases cause two-thirds of mortality in the US and consume 86% of annual healthcare spending.
Complicating this picture are two realities. First, 20-29% of the cost of chronic diseases is spent on treating potentially avoidable complications. Second, nonadherence to treatment can cost $2,000 to $8,000 per patient every year.
Incredibly, the World Health Organization (WHO) estimates that up to 80% of premature heart disease, stroke, and type 2 diabetes, and 40% of cancers could be avoided entirely if Americans did three things -- avoided tobacco, ate healthier foods, and became more physically active.
Addressing the prevalence and impact of chronic disease has become a major focus of new payment models, innovation grants, and government and health plan focus. Yet, no one entity can change the trajectory of chronic illness alone.
Partnerships are essential to addressing and preventing chronic illness.
Chronic disease models of care rely on partnerships
New models of care have emerged and evolved to better address chronic disease management. These models are based on patient‐centered medical homes (PCMH), team-based care, chronic care management, community health workers, accountable care organizations (ACOs), advanced primary care, and behavioral health integration.
Leveraging the strengths, skills, and technologies that partnerships deliver enables healthcare teams to achieve better patient health outcomes and higher quality of life at a lower overall cost, delivering whole-person, efficient care.
Clinical-community partnerships are key
Clinical-community linkages connect healthcare providers, community or non-profit organizations, and public health agencies to pull data, expertise, and resources to deliver evidence-based preventive and chronic care services.
A partnership among these entities can support four main goals, including:
- Coordinate delivery among medical, social, behavioral, and supplemental services.
- Fill gaps that thwart the medical treatment plan and any downstream dependencies.
- Provide whole-person care that meets people where they are and connects them to ongoing support and resources to be successful.
- Lower the cost or investment that any one organization would be required to make to deliver additional services alone.
One example of how clinical-community linkages work is in South Carolina.
The Healthy Columbia initiative features partnerships to increase access to care and reduce rates of chronic disease, emergency department utilization, and hospitalization. Trained volunteers screen for blood pressure and diabetes, provide peer-to-peer health coaching, and build community gardens where vegetables are inaccessible.
With more than 200 volunteers from local churches, civic organizations, local fraternities and sororities, and healthcare organizations, the community has engaged patients who now see their responsibility for their health and the use of healthcare as part of the bigger system.
System-oriented Chronic Care Management and Community Health Action Teams
Chronic care management (CCM) provides an organized, systematic, and person-centric approach to treating ongoing illness while enhancing the quality of life and lessening exacerbation and illness progression. Patients benefit from collaboration when a CCM program—whether initiated and led by a medical group or health system—joins forces with the community.
Chronic care management programs may partner with area pharmacists to provide convenience but also to strengthen everyday connections among patients, healthcare, and the community.
Community Health Action Teams (CHATs) are another partnership strategy where various community organizations centered around the area medical group, hospital, or health system use data analysis and population health management approaches to identify community health issues.
Then, with input from the community, they collaborate on how to triage those needs and work to improve health. This is particularly impactful where certain chronic diseases are highly prevalent.
A CHAT program through the Shawano County Rural Health Initiative identified that many local farming families were uninsured or had inadequate coverage. Due to cost or access, these families often skipped check-ups or treatment for chronic conditions.
The program leveraged rural health coordinators to visit more than 325 farms, or 40% of farms in the county, to provide health information, perform screenings, and connect residents to needed health and social services. Registered nurses received training for this initiative, which sets up follow-up and referral connections to medical groups and health systems for further diagnoses and treatment.
Community Health Workers
Community health workers (CHWs) not only promote cultural competence in chronic disease management and bridge language gaps for underserved populations, but they help make health care and its system more approachable and accessible. They can also lessen the stigma around disease through education and shared experience.
A recent NYU Grossman School of Medicine study shows that CHWs can help patients achieve optimal blood pressure control and better chronic disease management.
When associated with chronic care management (CCM) programs through a medical group, hospital, or health system, CHWs provide a direct and personal connection in the community empowered to take action on the patient’s behalf. Leveraging CCM, remote patient monitoring, behavioral health, or other digital technologies, CHWs can create a powerful link with clinicians and healthcare teams who can support patients on a pathway to better health.
A CHW-based care model working with individuals with high-risk diabetes in rural Appalachia helped patients achieve a mean decrease in HbA1c of 2.4 percentage points. Plus, within 6 to 12 months, more than 60% of patients with diabetes lowered their blood glucose between baseline.
Optimizing chronic disease management partnerships
Clinical practices, hospitals, and health systems of every size can tap into community connections and resources to improve population and individual health when it comes to preventing and treating chronic diseases.
Adding or expanding offerings like chronic care management, telehealth, remote patient monitoring, and behavioral health integration can not only open up new funding sources but meet the growing needs of patients living with chronic illness.
How ThoroughCare can help
ThoroughCare’s intuitive software platform can help providers collaborate and deliver digital care coordination, chronic care management, remote patient monitoring, and behavioral health integration. Our solution can help:
- Streamline the creation of patient care plans
- Support staff workflows with guided, validated assessments
- Help motivate patients through clinical recommendations
- Analyze patient risk factors and generate clinical recommendations
- Identify behavioral health conditions
- Track and log services for an audit-proof record of care
Additionally, ThoroughCare supports comprehensive integration with leading EHRs, health information exchanges, remote devices, and advance care plans, while helping providers visualize and interpret patient and operational data through analytics.
