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According to the CDC, six in ten Americans live with at least one chronic disease such as heart disease, hypertension, or diabetes. Chronic diseases are the leading causes of death and disability in America, and they are also a leading driver of healthcare costs.
Effective management of a chronic condition requires ongoing education, emotional support, encouragement, and coaching. These long-term conditions are better managed and even improved when patients change their behavior and make healthier lifestyle choices, but that is difficult for many to sustain. The challenge is even greater for patients who are managing more than one condition or face other barriers in managing their health. They can become overwhelmed and confused by complicated information and complex treatment regimens, which can lead to non-adherence to care plans and worsening conditions.
An innovative approach is required to control chronic conditions and have a positive impact on quality of life, delay disease progression, and result in better outcomes and lower costs.
Patients themselves can play a powerful role in managing one or more chronic conditions, but they need to understand what they can do to optimize treatment success and why it matters. They also need a close connection to their care team between visits so that adjustments can be made to care plans and medications in near real-time to prevent complications and delay disease progression.
In addition to the physical impact, chronic conditions can also lead to anxiety, depression, and other social issues. The negative impact of chronic conditions can be significantly alleviated with education, coaching, encouragement, social support, medication titration, and at-home monitoring tools, but care teams have limited time and resources, and delivering this level of support may be unrealistic.
Delivering individualized, ongoing support to every patient with a chronic condition is possible when using automated, proactive, and timely digital communication pathways. Care teams can leverage text-based, secure messaging protocols to supply information that supports self-management, provide encouragement, expand patient health literacy, sustain medication or device adherence, and help patients develop skills to manage their condition.
Patient engagement software can also deliver surveys that prompt patients to report how they are feeling, transmit data gathered using in-home remote physiologic monitoring (RPM) devices, and gather patient reported outcome measures (PROMs). This functionality enables providers to monitor important health data between in-person visits and proactively identify the need for medication titration or care plan changes. It also gives patients a direct connection to the care team so they can report barriers they are facing, both clinically and socially.
Digital communication pathways can be configured to alert care teams when patient reported metrics are out of range, so that they can intervene and prevent complications, unnecessary emergency department visits, hospital admissions, or the need for more aggressive therapy.
Care teams are empowered to focus their time on patients who need extra support, but also stay connected to those who are doing well. This added support keeps patients engaged throughout their healthcare journey and reduces the risk of deterioration.
Chronic illness is widespread and costly for patients and the healthcare system. Many conditions can be managed through treatment, lifestyle changes, and other interventions, but providers face many obstacles in connecting with patients between in-person visits. We must engage patients in their care to mitigate the impact of these conditions, and leverage technology to scale high quality, ongoing care to entire populations, ensuring that all patients have the tools they need to succeed.