Today, more than half of the U.S. population lives with at least one chronic condition, and nearly 30% have multiple chronic conditions. These chronic conditions—which include heart disease, hypertension, cancer, diabetes and, increasingly, long-Covid—are not only complex to manage, but expensive. According to a report by the Milken Institute, treating chronic disease costs payers and consumers more than $1.1 trillion annually in direct care costs.

And it’s only poised to get worse. With an aging population and a shortage of healthcare workers, our healthcare system cannot afford to properly care for people with chronic conditions in the ways it always has—that is, by relying on occasional check-ins at the provider site and DIY management. These methods fail to deliver the consistent care people need to effectively manage their conditions in between appointments and prevent acute symptoms that result in costly emergency visits and hospital stays.

To manage chronic care at scale, we must look at the issue with fresh eyes. We need to take stock of new digital solutions we have at our disposal and consider how these innovations can give way to more efficient and effective care delivery models.

The problems with chronic care management today 

Within most health systems, providers manage chronic conditions using the same basic model every consumer has come to know. A patient schedules an appointment with their doctor, the doctor evaluates the patient’s condition and suggests a treatment plan and the patient is tasked with managing their own care.

There are many problems with this model when it comes to chronic care. For one, people often struggle to follow through with their recommended treatment plan when left on their own. Sometimes they don’t understand exactly what they should be doing, and other times they have a hard time following their doctor’s recommendations. If people aren’t properly managing their disease, symptoms worsen, landing them in the hospital. This is not only detrimental to the patient, but costly for the healthcare system as well.

Even when patients follow their doctor’s guidance perfectly, their health can still deteriorate for reasons outside their control. When deterioration is not caught early, chronic patients often end up in the emergency department. This too results in less-than-optimal patient outcomes, as well as high costs of care.

The case for reimagined chronic care delivery

To truly move the needle on healthcare costs and outcomes, we need a more integrated care delivery model. This should fill in the gaps between scheduled appointments and foster more regular connections between healthcare consumers and their providers.

This model of care, for the most part, is still in its infancy. Chronic care health initiatives have largely been limited to patient communication solutions—messaging between provider and patient through a portal—and telehealth encounters: Zoom sessions between patients and doctors. While occasional messaging and episodic telehealth encounters serve their purpose, they do not provide the comprehensive, proactive care that people with chronic conditions require to stay out of the hospital.

What’s needed is regular patient monitoring and enhanced engagement to track how diseases present and evolve. Armed with real-time insights, providers can take a more proactive approach to managing care and prevent the costly hospital visits that occur when symptoms are not properly managed. In an evolving healthcare ecosystem, health systems are still uniquely able to deliver this model of longitudinal care due to the breadth of services that those living with chronic diseases may need over time.

Longitudinal care in action

What does it look like to fill in these gaps without exacerbating the strains on clinician staffing? Consider this patient journey:

Carol is a patient with congestive heart failure who has gone to the hospital twice in the last three months for fluid overload and shortness of breath. The cardiology department identifies Carol as having trouble managing her disease, so they ask if she’d be willing to enroll in a chronic care program that includes a mobile app and a Bluetooth-connected scale.

In addition to tracking her weight, Carol receives regular prompts through the app to report her symptoms, along with task and activity reminders. When necessary, she exchanges messages or holds video calls with her provider, all through the app on her phone. Through this digitally enabled chronic care program, Carol can better manage her condition and successfully avoid hospitalization.

When, a year later, her condition deteriorates and she experiences an exacerbation that requires more acute care, Carol is assigned a hospital-at-home team who provide her with a passive, continuous vitals monitor and necessary in-home services. The hospital at home is able to see her trending vitals over time since it is all synced with the EHR. As a result, her care teams have the comprehensive details they need to understand Carol’s history and best path forward.

For patients like Carol with more advanced disease, digitally enabled at-home care can drastically reduce the frequency and overall number of hospital visits. By creating new models that enable more continuous patient tracking and engagement, we can slow disease progression, improve patient outcomes and unlock more efficient operating models for health systems of all shapes and sizes.

This model has become more familiar in the pandemic as hospitals looked for ways to keep in touch with patients more regularly from home. But making this approach widely accessible going forward will require new payment structures.

Today, most contemporary payment structures don’t support this approach to care: They compensate visits and admissions, but often not the low-touch care between encounters. Value-based payment structures and readmission penalties may incentivize longitudinal approaches to care. However, progress is slow, and even internal accounting can be an impediment to deploying this proactive approach to wellness. What’s required is leadership: Ample published evidence demonstrates the clinical and economic value of comprehensive care, but to get there, we need the commitment to bold and broad stakeholder buy-in.

Photo credit: AJ Watt, Getty Images