The aging of the American population is spurring the increased focus on efforts to provide better care for people with chronic conditions. This is the message of the HealthStream article, Manageable but Often Overlooked: Chronic Disease Treatment Will Play a Vital Role in Effective Population Health Efforts.
Chronic Illness Care Requires Multiple, Individualized Approaches
Chronic disease management should be seen as something to be individualized vs. trying to find that one great solution to fix all ills. For instance, treating chronic conditions such as diabetes is not simply a matter of getting patients to cooperate with medical advice. Because of age, infirmity, socioeconomic issues and more, effective treatment calls for personalized plans vs. a population care roadmap, says Judy Carden, a registered nurse and certified diabetes educator who is a diabetes clinician for Sharecare.
“I work with patients who have diabetes while they are hospitalized,” Carden says. “A lot of them also have COPD, so they are in the hospital for that or another illness, alongside anything that’s happening with their diabetes. We can get a lot done in the hospital setting as far as disease management, and that is where we have to work on education and preventive care as well.”
Case Management Is a Step in the Right Direction
Patients come to Carden via referral from doctors and nurses, and the care team reviews the patient’s medical history with her. That includes not just chart numbers, but family history and other information if it is available. The growth of a case-management system for diabetic patients, as well as those with COPD and other chronic diseases, is a step in the right direction but also just the first wave of a process which mostly lies outside the facility’s walls, Carden says.
“With the chart we can get a picture of their A1C and see if we can get that under control,” she explains. “We have clinicians in the hospitals who are doing this kind of case management when those patients come in, and then we try to get them connected with outpatient therapies, or education, so that everything that’s done to get conditions under control during hospitalization doesn’t go away once they are discharged.”
Regular Provider Involvement and Interaction Is Important
Research indicates that interaction with providers can and does lead to reduced readmissions and better patient outcomes, she says, adding that engagement also lowers healthcare spending on these patients. But it requires their initial and ongoing cooperation, which is why she says education may be the most important component of any population health management strategy.
“All the research, all the literature, points to that,” Carden says. “If patients know more, they follow directions better and get things like blood sugar under control. They can improve dramatically in just two or three months but need encouragement to keep up with the regimen. It’s much easier and cheaper to prevent a condition from happening, or worsening, than it is to treat something they already have.”
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