Education and team-based care: The two essentials to providing effective chronic care

Today, more Americans than ever are living and struggling with chronic health conditions. According to the CDC, roughly 70 percent of the population will die from a chronic disease and caring for those patients accounts for over 86 percent of the nation's healthcare spending.

A chronic condition, by its very definition, requires ongoing and attentive treatment by healthcare providers to attain optimal outcomes for their patients. This is no easy task, as healthcare resources are stretched to their breaking point and the prevalence of chronic diseases are rising at an alarming rate. The market is at the tip of the proverbial iceberg of what is undoubtedly an epidemic, as chronic diseases account for the majority of deaths in the United States and globally. However, there are best practices for managing the vast population of chronic diseases such as diabetes.

There are two approaches for caring for chronically ill patients: a team-based strategy involves a cross-departmental collection of providers caring for one patient while a patient-centered method brings the patient into the decision-making process of creating an individualized plan for care. These two strategies are not mutually exclusive, but they aren't correlated either.

Compliance vs. Adherence
A common challenge for providers and educators is engaging patients to proactively participate in their care and adhere to the designated plan of action. It is reasonable to assume that most patients inherently want to be well, but they can become frustrated and exhausted in dealing with the daily grind that is diabetes care and often give up.

Providers continue to struggle with the terms compliance vs. adherence when describing a patient's ability to follow a plan of care. The distinguishing factor is that adherence allows the patient to participate in the self-management of their disease rather than yielding themselves to a proposed regimen from the healthcare provider. When a patient adheres to a treatment plan they are collaborating with their provider to develop and execute next steps together, increasing engagement and employing a team-based and patient-centered approach to care.

In order to enhance care quality, providers and educators need to address the challenge of improving adherence and therefore outcomes. It is not enough to continue approaching diabetes care, or any chronic illness, with traditional episodic one-on-one care as these types of diseases need the collaborative assistance of an interdisciplinary team, calling for a different strategy such as a team-based and/or patient-centered approach to care.

Despite an expanding portfolio of diabetes medications available and strong efforts to expand diabetes education programs, the outcomes for these patients remain relatively poor. When caring for members of the chronic care population, there needs to be a shift in the care model to involve the patient, educators, and additional team members, which will impact treatment plans, patient engagement, and ultimately outcomes.

Self-Managed Care
Continuing with the example of diabetes, the disease is extremely personal beyond the differences between type 1 and type 2 diabetes, each person has different treatment goals, medication needs, and required insulin doses. As such, effective care depends upon a patient's adherence to their customized and recommended plan of action. When patients are not adhering to their plan, it is imperative to identify the root cause and combat it to begin re-engaging with them.

There are four common factors that impact adherence.
• Financial issues often force patients to choose between medical costs and other living expenses
• Adverse side effects can include hypoglycemia, swelling, nausea, etc. and may result in ED visits or hospitalization. These side effects can cause patients to discontinue treatment
• Knowledge deficits regarding the multiple aspects of their care plan, including medications, exercise, diet, hypoglycemia treatment, etc. also hinder one's ability to adhere
• Psychosocial challenges such as depression, a common comorbid condition in people with diabetes, can deter patients from continuing with their plan

Once the barrier is identified, team-based care and disease education are instrumental in engaging patients as well as improving adherence. Understanding new concepts, technology and benefits of medication regimens are essential to this strategy. Education is best delivered by a team of providers and Certified Diabetes Educators across multiple disciplines, but is often underutilized, as it can be costly and difficult to find local experts. Since people learn in a variety of ways: reading, writing, observing, listening, etc., providers need to utilize a form of education that best suits their patient's learning style to increase their likelihood of self-management of diabetes. Embracing social media platforms (Twitter, Blogs, Facebook, etc.) is an effective manner for patients to communicate with their peers and share their struggles in diabetes management, fostering community. These touch points also serve as a launching point for long-term diabetes self-management support as patients connect with one another.

Standardization of Chronic Care Processes
Clinicians and experts are often asked, "How can healthcare providers standardize the care of patients with chronic diseases?" Standardization of care processes for patients with chronic diseases can result in improved care quality, increased drug adherence, enhanced patient outcomes and reduced costs. It is important for providers to individualize therapy and maintain a patient-centered approach, as recommended by clinical guidelines published by numerous associations around the world to ensure optimal outcomes throughout standardization.

As value-based payment models begin to take effect, it is imperative that providers identify a consistent workflow to engage patients in their individualized care. The allocation of resources, both electronic and human, containing strategies to successfully manage a large population of patients is essential to the success of any chronic disease management program. In that same vein, overall positive population health management is a key to successful chronic disease management. Providers need to be able to identify, engage, and communicate successfully with patients who are struggling with their care – chronic or not. Going back to the diabetes example, providers must standardize a process to utilize electronic health records (EHRs) to mine the data and identify patient populations with diabetes and flag those who are at-risk by missing appointments, not achieving A1c, blood pressure, or lipid targets, frequently visiting the emergency room, requiring recurrent hospitalizations, not refilling their medications, and who are missing their specialty appointments.

There must be a team-based approach to care in place to engage these patients once they are identified by working with care coordinators, educators, providers, etc. These struggling patients may require frequent communications, at times daily, in order to keep these individuals out of the hospital and encourage their adherence to the personalized care plan. This requires both manpower and technology, but providers should be vigilant about engaging with patients through their preferred methods, such as text messages, e-mail, phone calls, telehealth visits or even "snail" mail. Successful chronic disease management includes standardizing a process to identify the at-risk patients, and then individualizing their engagement, education, and treatment through a team-based and patient-centered approach.

Dr. Rhinehart, Chris Buck and Donna Doherty work at Glytec, the pioneer and leader of in providing innovative, FDA-cleared therapy management software solutions

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