Electronic Health Reporter

By Lee Horner, CEO, Synzi.

The statistics related to chronic disease management are staggering. According to the US National Center for Health Statistics, 40 percent of the US population have chronic conditions and almost one-third of this patient population has multiple chronic conditions. It’s a struggle to manage and engage these patients and keep the “sickest of the sick” at home, receiving care, vs. returning to the hospital or another facility. These high-risk members are also the most expensive. The treatment of patients with chronic conditions accounts for three-quarters of the $2.2 trillion in healthcare spending, with roughly 96 cents per dollar spent in Medicare and 83 cents per dollar in Medicaid, according to the CDC.

Unfortunately, these patients may be “frequent fliers” in a health system; they typically need more attention between care appointments and often rely on emergency medical services and/or the emergency room to answer questions and provide care in non-critical situations. Significant opportunities exist for technology and touchpoints to bring ongoing care and support closer to these patients. Virtual care technology can improve care coordination and increase patient access to convenient care 24/7. Frequent touchpoints can continually engage chronic care patients, resulting in better disease management, improved outcomes and reduced costs.

Post-acute care organizations are embracing the use of a virtual care communication platform to engage chronic care patients and optimize their agency’s available resources. Using a combination of a video-based platform and readily available smartphones, tablets and PCs, home health clinicians can quickly connect, communicate and collaborate with patients – and colleagues — to ensure patients are actively monitored and motivated in their care without a series of in-home visits.

Ongoing messages and a series of virtual visits can augment – and even replace – many traditional in-person visits, effectively reducing the costs and liabilities associated with nurses driving to each patient’s home. The virtual visit can also include a clinician, a pharmacist and even an interpreter, depending on the patient’s needs. During virtual visits, home health providers can use video to detect potential patient issues before an in-person consult is needed and deliver preventive care during the call, minimizing the need for an immediate in-person intervention.

Between virtual visits, the agency’s care team can stay in touch with patients by using HIPAA-compliant text and email messaging to remind patients of upcoming appointments, medication adherence, and general lifestyle recommendations. Time allocated to drive to patients, see patients and resolve patient issues can be repurposed into time focused on seeing patients and resolving patient issues. As a result, an agency’s available staffing resources are better utilized and the agency is able to increase the patient load and the bottom line.

Patients are empowered to actively participate in their care by having the ability to simply connect – at any time – with a member of their post-acute care team. To drive patient understanding of the condition and the need for adherence, the patient’s family caregivers can also be included in the ongoing communications and messages. Video technology bridges the geographical gap between the patient’s home and the family member’s location and also reduces the time and travel expenses typically incurred by family members when aiming to “be there” for their loved ones’ appointments.

To better manage population health, a home health agency’s administrator can review patient behavior (e.g., patients’ opening messages, participating in virtual visits, and requesting care on-demand) and determine if additional actions are needed. For example, an administrator can immediately direct a home health clinician to reach out to a patient if a patient appears to not have been engaged in the ongoing communications. The ongoing monitoring of patient behavior can actively reduce the unnecessary (and costly) ER visits and re-hospitalizations. Patients with chronic conditions receive only 56 percent of recommended preventive health care services per the New England Journal of Medicine. Virtual care technology can help remedy the situation.

By 2020, the U.S. patient population with chronic diseases is estimated to increase by 18 percent. The continued impact on patients’ lives and their quality of live is inspiring more post-acute care organizations to leverage virtual care technology to better manage and engage these patients. Patient engagement strategies can help patients better understand their health situation and remain aware of their evolving role in self-care throughout the continuum of care. The timing of the delivery of the information is as important as the message itself. As Stanford Medicine X patient advocate and Hugo Campos stated, “No patient wants to engage with healthcare. They want to engage with life.”