Chronic disease management has long been viewed as the central priority in healthcare, as providers work to improve patient outcomes and cut healthcare costs. That is, until the COVID-19 pandemic struck.
Since the beginning of March, chronic care has taken a back seat as the industry turned its eye toward mitigating the symptoms of COVID-19 and quelling its spread. Healthcare organizations, including primary care clinics — which serve as the epicenter for chronic care management — had to shutter their doors to non-urgent care. This came in an effort to promote safe social distancing.
Meanwhile, chronically ill patients, who are deemed at highest risk for contracting the novel coronavirus and experiencing more severe symptoms, have worked to stay out of harm’s way. This included avoiding healthcare access.
At the end of April, health data firm Evidation reported that 21 percent of chronic disease patients were worried about maintaining their healthcare, and 53 percent said they were worried about visiting a healthcare facility for a non-COVID-19 care need.
But there’s a paradox here. A chronically ill patient may be avoiding the doctor’s office because she’s afraid she’ll contract COVID-19 there. But as care access falters, she runs the risk of her illness getting worse. If that happens, the patient could experience a high-acuity care episode and end up in the ED, the very place she was trying to avoid in the first place.
Even as the nation begins to see a flattened curve and lower COVID-19 rates, it can expect these care access trends to continue.
That means chronic disease management will need to look a little different. Healthcare organizations may consider patient engagement technologies like remote patient monitoring, secure direct messaging, and telehealth tools to support remote chronic disease management.
REMOTE PATIENT MONITORING TECHNOLOGIES
Remote patient monitoring technologies, like blood glucose monitors or Bluetooth-enabled blood pressure cuffs, are effective at helping providers connect with patients without an in-person encounter.
These tools work exactly as they sound: they measure key patient metrics or vital signs, and if they are Bluetooth-enabled, they can populate the EHR with key patient-generated health data. Should any irregularities arise, clinicians may receive a notification to escalate the level of patient care, ranging from a motivating secure direct message to a telehealth encounter to an in-person encounter, depending on the severity of the result.
These technologies can also be effective without that direct EHR connectivity, although the process is more arduous. Patients with a traditional blood pressure cuff may input the PGHD into a certain part of the patient portal to prompt clinician review.
Of course, there are some challenges associated with remote patient monitoring tools, not least of which include cost. These technologies can be expensive, and it is a tall order to ask patients to foot that bill. At the same time, reimbursement for such tools hasn’t caught on the way telehealth and direct message consultations have, leaving some clinics and hospitals to provide these technologies at their own expense. This can be prohibitive for resource-strapped clinics.
That was the problem for Maria Barrell, DO, whose primary care clinic Primary Medical Group has been contending with remote chronic disease management since March. While many of Barrell’s patients have their own monitors at home, the lack of funding for clinic-issued tools has been challenging.
“We utilize what we can in terms of them monitoring their own conditions, but we were kind of ill-prepared as a country,” Barrell told PatientEngagementHIT in April. “There are obviously a lot of available resources to really do this in a big scale way, with Bluetooth-enabled remote monitoring systems and all of that, but the vast majority of people don’t have that. We don’t have the funding to distribute all of this to everyone.”
Although bigger organizations may have access to these tools and benefit from them, reimbursement rules may need to change to create widespread availability for smaller practices.
SECURE DIRECT MESSAGING
Secure direct messaging has emerged as a key strategy not only to connect with patients at a social distance but also to drive down patient volumes in call centers and via telehealth.
This technology, which has long been central in the patient portal, allows patients and providers to exchange quick messages about care. Secure direct messaging has long been regarded as a tool that can help keep patients out of the hospital when it can be avoided, but has only now seen its full potential.
The Department of Veterans Affairs, for example, leaned on its patient portal and secure direct messaging systems during the pandemic.
“The Oklahoma City VA Health Care System is committed to providing high-quality care while keeping Veterans safe from the coronavirus (COVID-19),” said Wade Vlosich, the director of the OKCVAHCS. “Due to COVID-19 precautionary measures and out of concern for our veterans, we are honoring current social isolation and distancing guidelines.”
“Through VA’s virtual care tools, we are able to leverage available technology to make sure that our patients and staff are as safe as possible during this time,” Vlosich added. “To help us address our Veterans’ most-urgent needs first, we ask that Veterans use our online tools for routine or non-urgent questions.”
OKCVAHCS and other VA facilities across the country encouraged patients to utilize tools like secure direct messaging to first run any medical questions by their providers at a safe social distance. Providers and patients could proceed either via video visit or referral to an in-person visit if symptoms were urgent.
This tool is well-poised for chronic care patients, who need frequent but low-acuity check-ins with their providers. Virtual visits and remote patient monitoring, while effective, can be more time-consuming and costly than secure direct messaging.
This patient portal functionality is key for chronic care patients with exceptionally low-acuity care needs but who need to maintain contact with their clinicians.
TELEHEALTH CARE ACCESS
Perhaps most notable of all, telehealth access has soared during the COVID-19 crisis as medical professionals work to maintain chronic disease management at a safe social distance. For Barrell, telehealth was a cost-effective way to keep the primary care clinic doors open and do right by her patients.
“There are a lot of primary care offices that are already furloughing employees, and there are a lot that are at-risk for financial compromise and closure,” Barrell said. “We wanted to make sure that doesn’t happen to us. Because if our lights aren’t on, then we can’t take care of our patients.”
The telehealth rollout happened within a matter of five to 10 days, and since then the primary care practice has been able to maintain much of its chronic disease management.
This story has been seen across the country, with many clinics also tapping telehealth to assess low-risk patients presenting with COVID symptoms.
But it’s the chronic disease management populations who have benefitted the most, Barrell contended. With or without a COVID-19 diagnosis, this pandemic has had disastrous implications for chronic care, and telehealth has been a bright spot in the past several months.
“I’ve got diabetics and patients with COPD who are terrified to go into the doctor, see a specialist, or even go to the ER, because everyone has clearly said to stay home. So they’re all staying home, but then they’re getting worse,” she continued. “And then they have to go to the hospital in a very compromised position. And their risk of being admitted is much higher and then paradoxically, their risk of exposure to COVID, which is what they’re hoping to avoid, is higher than it was in the first place.”
Of course, traditional telehealth strategies have not been perfect, and providers and payers alike have had to be flexible. Both private and public payers have reworked reimbursement policies to make it easier for providers to deliver effective telehealth care.
And for Barrell, technology limitations have meant she had to get creative about how to conduct visits. Telephone visits, for example, became far easier for some patient populations, especially adults who struggled with the video features but who could not lean on family support per social distancing guidelines.
Ultimately the technology has been a net positive, Barrell remarked, bringing together a team of caregivers who otherwise might go underutilized during this critical time.
“It pulls together this kind of this remote care team in a way that’s really streamlined and efficient. It helps keep patients out of the hospital and help make sure that our chronic condition patients are taken care of,” she said.
“Telehealth really empowers the primary care provider to be the complete custodian of the patient and reduces the risk of hospitalization and ultimately reduces the risk of morbidity and mortality associated with their underlying chronic disease.”
PROMOTING DIGITAL HEALTH LITERACY
Of course, none of these remote patient engagement technologies could work without strong digital health literacy. Digital health literacy refers to the comfort with which a patient may use digital health technology.
That level of comfort hinges on a few key factors. Foremost, the patient must understand how to use technology. Second, the patient must know that technology exists. Finally, the patient must see value in the technology and be motivated to use it.
But 2016 data published in the Journal of Medical Internet Research found that only about 16 percent of patients have adequate digital health literacy. And it’s that notion that is causing some concern for organizations ramping up their remote chronic disease management efforts.
For Kevin Davison, the vice president for business development & strategic services at the Southern California-based MemorialCare, addressing digital health literacy was tantamount to their care management efforts.
“Initially when we were rolling out our technology, we were thinking, how do we make sure patients are prepared and have the technology that they need? We were also thinking about how to navigate the technology troubleshoot on their own,” Davidson told PatientEngagementHIT.
Davidson, whose organization ramped up its telehealth use in light of the pandemic, knew everyone could be susceptible to some connectivity and technology snags. It was important that MemorialCare prepare patients for the potential for those snags and give them the tools to address issues on their own.
“We started by combing our schedule to identify care that could be dealt with via video and then proactively reached out to those patients to educate them about the technology and make sure that they were prepared and ready for their visit,” Davison explained. “But then we also equip the providers with some troubleshooting techniques.”
Clinicians come to telehealth and virtual care encounters armed with different tactics that could mitigate patient concerns should the technology not cooperate. For example, clinicians were instructed to call the patient if the telehealth technology experienced a pitfall. That way, the clinician could still speak with the patient and work through the problem alongside the patient.
As patients continue to face the threat of COVID-19 infection, healthcare leaders can expect to see lower utilization rates persist. This could spell big issues for chronic disease management if clinicians do not pivot to virtual care and drive patient health literacy.
Moving forward, medical organizations should consider which solutions are best suited for their unique patient populations and outline a strategy to prepare both patients and providers for the change. In doing so, organizations may increase patient engagement in care, delivering on better outcomes and preventing costly high-acuity episodes down the line.