Where to Focus on Improving Chronic Disease Care


Post by Deb Leyva


Account Executive, Caradigm

Strategies for chronic disease management have to evolve because of the enormous increase in patient volume that’s expected. CMS statistics cited in this article project that the number of total people covered by Medicare will jump from 55.3 million in 2015 to 80 million by 2030.[1] Today, about 69 percent of Medicare patients have two or more chronic conditions.[2] Faced with an aging and co-morbid population, health practitioners are being pressed to identify the right strategies to prevent chronic disease and lower costs.

The challenge is knowing where to focus initial efforts. Many organizations are continuing to experiment in accountable care, however the overwhelming majority have found it difficult to lower the cost of care for a defined population. To explore this topic further, I thought it would be helpful to revisit this article by the Centers for Disease Control and Prevention (CDC) that listed four domains that providers should think about when seeking to improve chronic disease care.

Domain 1: Epidemiology and Surveillance: Gather, analyze, and disseminate data and information and conduct evaluation to inform, prioritize, deliver, and monitor programs and population health.

Domain 2: Environmental approaches that promote health and support and reinforce healthful behaviors (statewide in schools and childcare, worksites, and communities).

Domain 3: Health system interventions to improve the effective delivery and use of clinical and other preventive services in order to prevent disease, detect diseases early, and reduce or eliminate risk factors and mitigate or manage complications.

Domain 4: Strategies to improve community-clinical linkages ensuring that communities support and clinics refer patients to programs that improve management of chronic conditions. Such interventions ensure those with or at high risk for chronic diseases have access to quality community resources to best manage their conditions or disease risk.

To encapsulate these domains, the CDC is recommending care that is preventive, coordinated and engages patients. Also heavily implied in the domains is the idea that new health IT infrastructure is needed to support these changes. While I believe that these recommendations are fundamentally sound, they are broad and don’t specify where providers should focus.

Many of Caradigm’s customers choose to start with improving care coordination because of its central importance to driving population health. The importance is highlighted further because care coordination impacts all of the CDC Domains. For example, the ability to aggregate and share data (Domain 1) should be part and parcel of care coordination improvement efforts. So should increasing the use of preventive care (Domain 3) as well as the linkage with community-based organizations (Domain 4). Improving patient engagement (Domain 2) for co-morbid patients typically needs to be led by care managers through high-touch efforts involving a team of clinicians, family members and friends.

In my role with Caradigm as a customer account manager, I can tell you that it’s amazing to be in the room with a customer that has reached a consensus on their top population health priorities. For example, they may lay out the four or five specific care management workflows they want to improve first. Defining clear goals and a path to achieve them is a huge achievement in of itself. There’s no question that changing how an organization cares for the chronically ill is a long-term and highly iterative pursuit. No one has all the answers today, but focusing your efforts gives you a better chance to drive initial results and build momentum for your overall population health strategy.

[1] Sullivan, Tom. Chronic care management: Is the $50 billion market more hype than reality? HealthcareIT News. April 26, 2016.

[2] Lochner, Kimberly A ScD and Cox, Christine S, MA. Prevalence of Multiple Chronic Conditions Among Medicare Beneficiaries, United States, 2010. Originally published: http://www.cdc.gov/pcd/issues/2013/12_0137.htm