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Multiple Chronic Conditions Require Us to Restructure Health Care Delivery

Jane Pederson
Jane Pederson, MD, MS
Chief Medical Quality Officer
Stratis Health

Caring for individuals with multiple chronic conditions will require fundamental changes to our health care system. The current health care model is ideally suited to address conditions that generally result from a single cause. Current evidence and many of the tools, such as clinical guidelines, are single disease focused. Simply applying multiple single disease-focused guidelines to an individual with multiple chronic conditions leads to a lack of coordinated care and increases the potential for adverse outcomes such as medication interactions.

Chronic condition management needs to extend well beyond continuing care over time. There are social and psychological elements to living with a chronic condition—a greater impact on family and caregivers, financial burdens, as well as employment and lifestyle considerations. Addressing these broader needs over time requires a team-based approach to care that can draw on the skills of clinicians, as well as other disciplines in the community.

The mismatch between our current model of care and the needs of a growing number of individuals with multiple chronic conditions calls for new approaches to care that support ongoing monitoring and management of chronic conditions with the goal of optimizing quality of life and wellbeing.

Patient leadership

One of the biggest shifts that needs to occur in the management of multiple chronic conditions is who is setting the goals of care and leading the health care team. In the management of acute conditions, leadership falls to the clinicians who diagnose the problem and stabilize the acute disease process by initiating treatment. In chronic conditions, leadership of the health care team needs to transfer to the person that is intimately impacted by the chronic condition—the patient. This paradigm shift is well beyond what is often referred to as patient engagement. Patient leadership means the individual sets the goals of care, guided by other members of the health care team who apply their knowledge, expertise, and access to services to achieve those goals and adjust them over time.

New care delivery approaches

This shift requires many other new ways of thinking about care delivery, including:

  • Location of care. People live with and manage multiple chronic conditions in their homes and workplaces, not in a clinic exam room. To best support the person with chronic conditions, team members need to make recommendations in the context of the patient’s life. The team needs to go to the patient, instead of the patient coming to them.
  • Coordinated and consistent communication. Electronic record systems must communicate fully and efficiently. Patients need ready access to all team member communication, which means documentation supports care-related communication. Language influenced by billing requirements often is not in line with what the patient needs or wants.
  • Predictive data. Real-time patient derived data combined with historical data from the health care record should be used to monitor chronic conditions to stave off the need for interventions. The health care team’s workflow must be designed to support prompt identification and intervention.
  • Optimizing individual care. An evidence base and performance measures are needed to optimize care for individuals rather than single disease states. Research is needed to determine how resources, such as clinical guidelines, can address multiple chronic conditions. Performance measures need to be restructured to remove disincentives for clinicians to optimize care for individuals with multiple chronic conditions.
  • Remote access. Technology should be used to eliminate barriers to communication. Some patients have challenges meeting face-to-face with members of the health care team because of distance or lack of transportation. Workflow and reimbursement must adapt to make the use of remote technology, such as video conferencing, common practice.

Positive changes are occurring in the health care system to improve the care for individuals with chronic conditions, and payment models are evolving to meet these needs. Putting the patient in a leadership role on the health care team and creating models where team members work in conjunction rather than in a vacuum or at odds with one another will require significant changes in how team members work and interact with each other. The growing number of individuals with multiple chronic conditions necessitates accelerating progress toward well-coordinated care that is aligned with the individual’s goals of care.