It takes creativity to help the chronically ill adhere
Cookie-cutter solutions just won't cut it
Recognizing the importance of helping people with chronic conditions keep their conditions under control and maximize their health, health plans and providers are trying innovative ways to persuade the chronically ill to adhere to their treatment plans.
Executive Summary
Chronic diseases are the nation's leading cause of death and most are preventable, but helping people keep them under control is a challenge for the healthcare industry.
- There's no one-size-fits-all solution. Case managers need to take an individual approach, experts say. For example:
- Drill down and find out everything you can about your patients and identify any roadblocks to adherence, such as social needs and psychosocial problems.
- Take the time to make sure patients really understand their disease and how to manage it.
- Leverage technology to stay in touch with at-risk patients.
Chronic diseases are the nation's leading cause of death and disability and account for about 75% of all healthcare expenditures, according to the Centers for Disease Control and Prevention in Atlanta.
Although chronic disease is largely preventable, seven in 10 deaths in this country are caused by chronic disease, the CDC says.
"Since 75% of healthcare spending is on chronic diseases, prevention and cost-effective treatment are essential. It's more than just a fiscal issue, but perhaps is even a national competitive and security issue," says Bern Shen, MD, chief medical officer of HealthCrowd, a Silicon Valley-based mobile health company.
Helping people manage their chronic diseases is our country's biggest healthcare challenge, says Marcia Diane Ward, RN, CCM, PMP, a case management consultant based in Columbus, OH.
There's no one-size-fits-all solution, Ward points out. "Human beings are all unique, not just physiologically but in how they manage their health. You can't expect cookie-cutter disease management to work," she says.
Recognize that people are individuals and need an individual approach, she says. Talk to your patients and drill down to determine their situation at home and any psychosocial needs.
"Patient engagement has been called the blockbuster drug of the 21st century," Shen says, quoting Leonard Kish, a healthcare information technology strategy consultant.1
"Adherence to medication regimens, diet, exercise, and other behavioral prescriptions is key for both primary and secondary prevention," Shen says.
Non-adherence is not often a problem when the medical condition is acutely painful, Shen points out. On the other hand, many chronic diseases, such as hypertension, are relatively asymptomatic, and it's a challenge to keep patients from making unhealthy choices. "Often, short-term rewards trump long-term ones," he says.
One of the most challenging populations to engage are people who are barely scraping by and who need social support, Ward adds.
"When people are about to be evicted or have no food in the house for their children, checking their blood sugar or taking their medication is not going to be a priority," says Pamme Taylor, vice president for advocacy and community-based programs for WellCare Health Plans, headquartered in Tampa, FL.
WellCare is contracting with social safety net organizations to implement the Stanford Chronic Disease/Diabetes Self-Management Program. "It's a situation that benefits everyone. The organizations get much-needed funds. We get disease management services for our members, and the members receive the training they need to stay healthy from an organization they know and trust," Taylor says. (For details on how the program works, see related article on page 43.)
Some patients don't understand the consequences of not taking their medication or not following through with their discharge plan, Ward points out. "Many times they're given the information in a hurry at the point of discharge when they are thinking about going home and they may be under the effects of medication. It may take a number of sessions with a case manager for the information to sink in," she says.
Physicians simply don't have the time it sometimes takes to teach patients how to manage their condition and how to take their medication, Ward adds.
That's why Capital District Physicians' Health Plan (CDPHP), headquartered in Albany, NY, developed a medication therapy management program in which pharmacists meet face-to-face with patients in patient-centered medical homes or community pharmacies, conduct medication reconciliation, and educate patients on their medication. When needed, the pharmacists teach patients how to give themselves injections, use inhalers, or use other medical devices. "This approach is improving quality of care and reducing preventable hospital admissions and readmissions," says Eileen F. Wood, RPH, MBA, vice president for pharmacy and health quality programs for CDPHP. (For details on the program, see related article on this page.)
The aging population means a surge in the need for healthcare as clinicians are aging out of the workforce, Shen says. "This means our society will have to do more with less. Technology is no panacea but it can help leverage scarce resources. Rapid technological innovation has so thoroughly permeated our everyday lives that consumers have come to expect similar levels of connectivity, information liquidity, and convenience in healthcare," he says.
Patients in the University of Iowa Hospitals and Clinics cardiac rehabilitation program who receive three to five weekly text messages complete more rehab sessions than people who do not participate in the text message program, says Patricia Lansbury, RN, BSN, Med, CCRN, cardiac rehabilitation consultant for the Iowa City-based hospital. The messages are a combination of heart healthy tips and requests for information on their activities.
"Text messages help us stay in touch with patients between sessions and alert us if the patients are getting into trouble. It takes less than five minutes twice a day to check the replies to the questions and intervene if there are problems," she says. (For details on the program, see article on page 42.)
UCare has found similar success with its telemonitoring program for at-risk heart failure patients, says Jodie Milner, RN, CHC, manager of health improvement for the Minneapolis-based health plan. (For details, see related article on page 41.) "People like the program so much they don't want to leave it," she says.
Some people are non-adherent because they have an altered mental state, such as dementia, addiction, or bipolar disorder, which makes it impossible to follow their treatment plan, Ward says. Depression is often a comorbidity in the chronically ill and can affect adherence, she adds. In those cases, case managers need to find out if their patients have caregiver support and engage them in the treatment plan and/or get patients connected to mental health services, she adds.
Other patients may not follow their treatment plan because they are recalcitrant to treatment, Ward says. "They don't believe what their doctor tells them or they just aren't committed to following the treatment plan. They can logically process the information they are given, but they simply are not going to comply," she says.
- Kish L. The Blockbuster Drug of the Century: An Engaged Patient. HL7 Standards, 28 August 2012. http://www.hl7standards.com/blog/2012/08/28/drug-of-the-century/ n
