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How to Scale Chronic Disease Management Programs

Because of the complexity of chronic disease, population health leaders often struggle to find scalable management approaches that improve outcomes and manage utilization. Our survey of chronic disease management programs identified common design flaws that lead to ineffective patient management and unmanaged costs.

First, programs often narrowly focus on treating disease in a short-term window (e.g., the 30-day period post-discharge) and miss opportunities to prevent disease and escalation outside those parameters. In addition, providers often overly-segment programs by disease state, leading to gaps in care and unnecessary duplication of resources. Finally, programs may not set clear guidelines for when patients should access high-cost services (e.g., remote patient monitoring, intensive nurse-led care management) leading to inefficient resource use.

This research report offers three recommendations for developing a scalable chronic disease management program.

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  1. Find modifiable patient risk factors. Rather than segment programs by disease, align services to modifiable risk factors agnostic of chronic condition. Identification tactics include root cause analyses, proactive outreach to engage all in-need patients, and tailored care planning including clinical and non-clinical indicators.
  2. Anchor consistent, long term services in ambulatory care. Organizations focus too narrowly on post-discharge care, rather than investing in upstream services that drive longitudinal engagement. Tier intervention options based on patient acuity, matching more costly and time-intensive options to higher risk patients. Key components include self-management support, medication support, psychosocial care, telehealth, and advanced illness care.
  3. Set clear pathways to specialists. PCPs don’t always know when patients can be managed in primary care or when they should be referred to specialty care. Offer decision support with hardwired coordination pathways, including real-time specialty consults and care compacts, to ensure seamless transitions and avoid acute utilization.

The future of value-based care

Medicare and Medicaid risk is progressing (slowly) — but commercial risk will determine whether the industry tips toward a new cost and quality standard.

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