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Quality Update - Health care quality issues for Minnesota's health care leaders

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How National Leaders Are Approaching Chronic Conditions

Six in 10 adults in the U.S. have a chronic disease, and four in 10 have two or more. In high-income countries, approximately 75 percent of deaths are caused by progressive advanced chronic conditions.

Costs for direct health care treatment of chronic health conditions in the U.S. totaled $1.1 trillion in 2016, according to the Milken Institute. Adding the indirect cost of lost economic productivity bumps the total cost to $3.7 trillion.

Many chronic diseases are caused by a short list of risk behaviors: tobacco use and exposure to secondhand smoke, poor nutrition, lack of physical activity, and excessive alcohol use.

Man running upstairsObesity: the greatest risk factor

In January 2019, a think tank of The Aspen Group, including Kathleen Sebelius and Tommy G. Thompson, declared that “obesity is the primary driver of our chronic disease crisis.”

Obesity is by far the greatest risk factor contributing to the burden of chronic diseases in the U.S. For the fastest growing chronic diseases, like diabetes and hypertension, their causes are rooted in obesity.

Obesity is underdiagnosed, making it difficult to manage as a comorbidity. A 2016 Cleveland Clinic study found that one in four patients with morbid obesity did not have a formal diagnosis. “Obesity is very prevalent and yet underdiagnosed, which is one of the top barriers to patients getting the best care,” said Bartolome Burguera, MD, director of Obesity Programs at Cleveland Clinic. More effort should be focused on helping patients with the primary problem of being overweight.

Health care: the right culture

An organizational culture that supports quality improvement and supportive managerial and medical leadership are two of the top facilitators of chronic care management processes cited by leaders of physician organizations.

A consensus is forming, based on evidence and outcomes, that person-centered care is needed to drive better outcomes and lower utilization costs. Organizations employing patient-centered models of care are improving the quality of care for patients with multiple chronic conditions.

Patients with both physical and mental health diagnoses included in an accountable care organization (ACO) report better physical functioning when the practices have patient-centered cultures. Medicaid beneficiaries with multiple chronic conditions enrolled in a Patient Centered Medical Home were more likely to receive eight recommended disease-specific mental and physical health services. In Minnesota, clinics participating in the Health Care Home model of care outperformed other clinics on quality measures.

An expert panel of the American Geriatrics Society identified eight key elements of person-centered care (see sidebar). When The Commonwealth Fund analyzed promising care models for adults with complex needs, nearly 70 percent of the models incorporated all eight key elements. More than 80 percent had at least seven.

The top three challenges to chronic disease management identified by executives, clinical leaders, and clinicians directly involved in health care delivery, noted in a NEJM Catalyst report, were lack of time for clinicians to see patients with chronic conditions (selected by 44% of respondents), insufficient care coordination to ensure best outcomes (39%), and lack of patient resources for self-management (27%).

To remove these barriers, patient-centered cultures need to be supported by payment models that allow clinicians to prioritize disease prevention over treatment. Organizations with larger revenue and infrastructure can be proactive in treating chronic diseases because they have morecomprehensive programming and are more able to take risk in pilot programs. Smaller health care delivery organizations may not have the scale or resources to be as proactive, indicated Eric Weil, MD, director of population health at Beth Israel Deaconess Medical Center, in the NEJM report.

Organizations working in value-based care models are more likely to be providing proactive and preventive care versus reactive care. Value-based care and capitated models, and direct payment for chronic care management services, like Medicare reimbursement, are allowing health care organizations to offer more proactive patient care for chronic diseases.

Individuals: removing barriers

Key Elements of Person-centered Care

  • Individualized, goal-oriented care plan based on a person’s preferences.
  • Ongoing review of a person’s goals and care plan preferences.
  • Care supported by an interprofessional team in which the person is an integral team member.
  • One primary or lead point of contact on the health care team.
  • Active coordination among all health care and supportive service providers.
  • Continual information sharing and integrated communication.
  • Education and training for providers and, when appropriate, for the person receiving services and those important to that person.
  • Performance measurement and quality improvement using feedback from the person receiving services and their caregivers.

Seven in 10 Americans say chronic diseases are usually due to factors and circumstances beyond a person’s control, according to a 2018 Kaiser Health Tracking Poll. Health care organizations are building workflows to identify patient risk factors based on social determinants, such as socioeconomic and physical environment factors, then link patients to resources that can address these issues.

“Several companies are pilot testing tools and methodologies for health care organizations to calculate return on investment for addressing social determinants of health,” said Sue Severson, Stratis Health vice president of health information technology. “We are excited to be weaving these tools into our work with health care organizations.”

The same Kaiser poll indicated that half of respondents say individuals themselves should play the largest role in preventing chronic disease. Behavior change is hard, which makes personal care plans all the more important for activating and engaging patients. Facebook uses 98 personal data points to target ads. Organizations should assess whether they use enough individual data to build personal care plans.

Health care staff need to be skilled at eliciting what matters to each individual and be able to connect how a patient’s health supports their quality of life. Staff also need to be able to assess a patient’s confidence in their ability to change behaviors and address perceptions of their capability. Individualized, goal-oriented care plans that break big goals into near-term achievable sub-goals can build patient confidence to continue their path to increased wellness.

Studies indicate that more than 10 hours of patient self-management support is beneficial to improve chronic conditions. The health care industry needs to find the most effective ways to target that support.

Several organizations are exploring the use of composite data about individual behaviors, feelings, and beliefs to tailor interventions for chronic disease prevention and management. Gathered from extensive interviews, this data is used to develop a set of patient personas, fictitious people who characterize patients with significant similarities. Interventions are then built or bundled to meet the needs of those representative personas to accelerate patient support. Patients might equate to a Struggling Sam or a Coping Clare, two of The Commonwealth Funds personas for individuals with three or more chronic conditions. Participants using persona-tailored learning have reported high levels of satisfaction with their online user experience and increased levels of activation about their health.

New and focused approaches to reduce the burden of chronic conditions are imperative for the health of individuals and for the health of our country