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August 30, 2017 Guest articles No Comments

The Importance of Technology in Ambulatory Care for Chronic Disease Management
By Allison Hart


Approximately 100 million people are affected by chronic pain in the United States, and, according to the CDC, nearly half of all adults in this country are suffering from one or more chronic health conditions. Not only are healthcare providers faced with the daunting task of caring for such a large population, but care for such conditions often require multifaceted treatment protocols to address a wide range of disorders. Due to this, care management for chronic patients can be costly – demanding additional healthcare resources and extensive treatment measures beyond the clinical setting.

Financial pressures and performance demands to keep chronic patients healthy have sparked efforts to find new ways of supporting patients during ambulatory care in order to maximize revenue, reduce readmission penalties, and improve outcomes for less. Due to the complexity of most chronic cases and the sheer number of patients, it is difficult for any organization to effectively manage and engage every patient outside of a clinical setting without the right tools.

According to a recent West survey, more than half of patients struggling with chronic disease are only somewhat confident, at best, when it comes to managing their condition. And, another 35 percent of these patients were not sure what their target numbers should be for key health indicators like blood pressure, cholesterol, and weight. In order to effectively manage chronic conditions, not only does each patient need to feel confident in their understanding of treatment adherence, but both patient and provider need to have a firm grasp on the patient’s daily health status in order to avoid declining health and costly hospitalizations.

Successful chronic disease management requires continuity of care. A patient’s checkup is only a small portion of managing a chronic disease, especially when dealing with complex conditions like diabetes that require frequent monitoring and balancing of insulin levels, weight, and blood pressure. Research has shown that patients have a strong desire to improve their quality of life, but in many cases, they are unsure how to make decisions or changes that will create real improvement. Healthcare providers can support chronic patients with engaging outreach and resources that give patients the knowledge they need to better manage their condition.

The Role of Remote Technology During Ambulatory Care

The rise in value-based payment models has prompted healthcare organizations to invest in more efficient methods of patient management – including technology-enabled communications – to help improve the quality of life for patients in a cost-effective way. The rise of biometric monitoring devices, such as pulse oximeters, blood glucose meters, and heart rate monitors is making it easier for physicians to closely monitor a patient’s health status remotely. But while tracking daily analytics is key to ensuring chronic patients are maintaining good health, it is only one aspect of treatment.

In addition to collecting data on a patient’s physical health, clinicians can also leverage existing automated reminder technology to create and schedule a series of communications to support the patient’s long-term health management plan. For example, a diabetic patient might receive notifications via email or text to remind them to take medications, schedule routine eye and extremity exams, or schedule an appointment for an A1C draw. Automated communications can also be used to lend preventive support to low-risk patients to provide educational materials such as recent research on how to manage their specific ailment, videos on diet or exercises, or links to support services. Pairing biometric device data with automated support during ambulatory care can help providers establish critical touch points for intervention, or better predict negative outcomes that might escalate into a readmission.

Automated Surveys Streamline Treatment Efforts

The use of surveys in chronic care management have traditionally been reserved for recently discharged patients and offer great insight into how a patient is coping outside of the clinical setting. In fact, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) surveys found that patients often expressed feeling disconnected from their medical team after discharge and even confused or uncertain about how to comply with care instructions after leaving the hospital. This type of information is paramount for case managers dealing with newly released patients, but could also prove invaluable for physicians caring for the long-term health of chronic patients in the ambulatory setting.

Surveys are currently underutilized by most providers as a chronic disease management tool. The same survey found that many providers monitoring the health of their chronic patients depend on in-person visits to ask questions, while only five percent stated they use survey check-ins that ask questions specifically about treatment plans. Not only is this a costly approach for both healthcare organizations and patients, but it lends itself to poor results in terms of accurately monitoring each patient’s progress on a consistent basis.

Similar to the HCAHPS, clinicians can leverage their automated reminder technology to more proactively and regularly send their chronic patients a series of questions regarding things like pain levels, medication compliance, and sleep patterns to determine if the patient is on track with treatment or if they need to intervene. Leveraging their EHR systems, care teams can also target efforts based on risk stratification – sending more in-depth questions to those more likely to develop complications. This method provides clinicians with a cost-effective method of collecting continual feedback on how each individual patient is coping during daily life. It also addresses the issue of patients feeling disconnected with their providers and makes them feel that their care team is engaged in their treatment journey.

Chronic disease management is complex and requires a multifaceted approach by providers and patients. The office visit is just the beginning of care – effective care management requires that providers and healthcare organizations incorporate the right tools and strategies in the ambulatory setting to reduce readmissions, engage patients, and prevent long-term cost deficits. Leveraging cost-effective technologies that allow patients and providers to stay connected on a day-to-day basis is changing the way doctors and patients approach chronic disease treatment.

Allison Hart is vice president of marketing for TeleVox Solutions at West in Omaha, NE.


Jenn, Mr. H, Lorre

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