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What providers need to do to improve chronic care


A West survey finds that an overwhelming number of chronic care patients say they need help managing their disease.

More provider support is essential for improving chronic care, according to findings from two new surveys.

According to West surveys on chronic disease and patient engagement, 91% of chronic care patients say they need help managing their disease. In fact, one in five patients believe they need 24-hour disease management assistance.

This report, "Strengthening Chronic Care," shares findings from the two West surveys on chronic disease management. The first survey, conducted by Kelton Research on behalf of West, collected insights from 502 adults in the U.S. that have at least one chronic health condition and have been hospitalized as a result of a chronic illness. The second survey was administered by West and targeted 417 healthcare providers. Survey responses helped identify some of the problems surrounding chronic care, and what it will take to address those issues.

One major problem facing both providers and patients is the fact that 39% of patients admit they're only somewhat knowledgeable, at best, about how to effectively manage their chronic condition, according to the findings.


“Providers can help patients do a better job of managing their health by supporting patients, not just during office visits, but also at home- where patients say they need the most help,” says Allison Hart, chief healthcare market research and insights strategist at West.

Patients do not have a good grasp on health metrics, according to the surveys.

“Many don’t know what their target health numbers are and whether they are within range, or even what numbers-like blood pressure, glucose levels, etc.-mean,” Hart says.

According to the findings:

• 43% of patients with a chronic condition are only somewhat confident, at best, they know their current health metrics. (e.g. blood pressure, cholesterol, weight)

• 75% of healthcare providers believe patients are not entirely aware of their current health metrics.

“Chronic disease is costly for healthcare providers, so there is a financial case for better chronic disease management,” Hart says. “Patients with chronic health conditions have been found to have higher hospital readmission rates, and the most frequent reasons for readmission are often related to chronic health conditions.”

Preventable hospital readmissions are estimated to account for more than $17 billion in Medicare expenditures annually, according to CMS. And, some of those Medicare costs are passed onto hospitals in the form of readmission penalties. Readmissions are estimated to cost hospitals $528 million in Medicare penalties for the 2017 fiscal year.

Under the Hospital Readmission Reduction Program (HRRP) around half of the hospitals in the U.S. were assigned payment penalties last year, according to Hart. “If hospitals and health systems don’t get a better handle on managing patients with chronic conditions, they are going to continue to face penalties,” she says.

Patient engagement drives opportunities to impact clinical outcomes, according to Hart. Eighty-eight percent of patients who want assistance managing their condition say ongoing support from their provider would make a difference in the overall state of health, according to the survey.

“Providers must seize engagement opportunities,” she says. “There are many different ways providers can engage patients and support them between visits. As the West survey findings show, patients desire personalized and targeted communications and information, and they also want regular check-ins from providers.”

Seventy-five percent of chronic patients want their healthcare provider to contact them regularly and alert them if anything looks wrong, according to the survey. However, only 30% of patients report receiving regular check-ins to review their progress.

Automated surveys allow providers to routinely monitor chronic patients, escalate cases where patients are at risk, and intervene before patients reach the point of needing acute care, says Hart. According to Strengthening Chronic Care: Patient Engagement Strategies for Better Management of Chronic Conditions, there is untapped potential for using patient surveys. Just 5% of providers say they use survey check-ins that ask patients questions about treatment plans.

“Biometric monitoring devices like heart rate monitors and blood pressure cuffs offer similar benefits as patient surveys,” she says. “These tools provide additional opportunities to engage and monitor patients at home, and could be leveraged more by providers.”

Next: Conditions where patient engagement can help



Three chronic conditions where better patient engagement can impact health outcome are:

•   Congestive heart failure

•   Diabetes

•   Chronic obstructive pulmonary disease (COPD)

“Surveying patients is an effective chronic care strategy,” Hart says. “Automated surveys allow providers to monitor patients in their home environment, escalate cases where patients are at risk, and intervene before patients reach the point of needing acute care.”

For example, to monitor patients with congestive heart failure (CHF), providers can assign a short touchtone survey to patients with this condition. A typical survey for this patient group would include less than 10 questions and be delivered to patients at home once or twice per week. After receiving an automated survey call, patients are directed to respond by pressing a number on their phone to answer questions about their current health status. Because weight gain can indicate problems in CHF patients, the survey might instruct patients to:

•   Press 1 if they are at their usual weight

•   Press 2 if their weight has increased up to 2 pounds from their usual weight

•   Press 3 if their weight has increased three to four pounds from their usual weight in the past week

Patients also might be asked to respond in a similar way to questions about their sleep, whether they are experiencing swelling, or having difficulty breathing.

“The idea is to use known signs that indicate potential problems in CHF patients to identify issues before they turn into major problems for patients,” Hart says. “The data are then reviewed and, if the data show signs the patient is experiencing trouble, the healthcare provider can intervene early to prevent an acute situation.”


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