Four emerging capabilities can bridge the gaps between in-person visits, which is critical for monitoring care regimens and ensuring issues are identified early on.


Digital platforms that help communicate with patients can connect them to resources to better manage chronic disease.

Chronic diseases are a growing concern for patients and healthcare organizations aiming to manage their conditions. According to the CDCsix out of 10 adults in the United States suffer from a chronic disease and four out of 10 have two or more such conditions.

Like this number continues to grow in the United States, it creates significant challenges for all parties involved. On average, one in 20 people is considered to be at high risk for poor health and high use of services due to the complexity of their health conditions and co-morbidities. This increases overall costs for health systems, adds pressure on already overstretched healthcare teams and negatively affects the quality of life of millions of people.

In light of these data, it is clear that the traditional self-management approach to chronic care management is not effective. Healthcare needs a new digital strategy to reduce barriers to care, identify gaps in care, slow disease progression and provide the extra support patients need, not just at infrequent visits at the clinic, but in the course of their daily lives.

Take advantage of digital technology

Relying on a manual approach to chronic care management presents significant challenges for healthcare providers who have limited time and resources. Adding automated digital solutions to identify patients who need additional support and provide care beyond the clinic can help patients follow their care plan, reduce burden on the care team, improve chronic care management efforts and help organizations succeed in value-based care.

This technology-driven approach can support a more sustainable and efficient solution for several reasons.

Scalability. Dedicating a member of the healthcare team to regularly monitor patients with chronic conditions and identify those who may be at risk of developing one is not feasible. However, with digital communication channels, such as this, care teams can monitor, educate and coach patients to keep them on track with their care plan without increasing the workload of the care team. This kind of automated, optimized patient engagement can improve outcomes across a range of chronic conditions, including hypertension, diabetes, and congestive heart failure through simple text-based communication.

Identify gaps in care. A technology-based solution, such as this can help close gaps in care that, if ignored, can lead to disease progression or other poor outcomes. Identifying gaps, such as missed routine screenings and health data related to chronic disease or chronic disease risk, is key to keeping patients as healthy as possible. Using the information built into their electronic health record system, providers can streamline pre-visit planning and close gaps at the point of care where it has the most impact. Patients receive more comprehensive care and benefit from more efficient and better planned visits.

Personalized patient communication. A care plan for managing a chronic condition can be confusing for patients. If they have more than one chronic condition, keeping track of medications and lifestyle changes can be overwhelming, especially if they face challenges like poor health literacy or language barriers. If patients do not understand their care plan or cannot follow it for any reason, there is a higher risk of non-compliance and health deterioration. Simple text-based communication channels can involving patients at every step. Using easy-to-understand language and prompts can help patients report issues or barriers so care teams can intervene. When patients can engage on their own terms and revisit resources and information whenever they want, they are able to succeed.

Remote patient monitoring. Health care tends to be episodic, so in-person visits can be weeks, months, or even longer intervals apart. Additionally, interactions with health care providers are also getting shorter, making it difficult to accurately diagnose a disease, adjust treatments, or resolve obstacles that patients face in their lives. daily. Remote patient monitoring is a valuable tool that improves connectivity between patients and care teams and provides more comprehensive monitoring of patient health and lifestyle.

Choose a strategy

As chronic diseases become more widespread, resources are stretched, and the social determinants of health continue to negatively impact certain populations, it is more important to stay in close contact with patients between visits and d proactive management of chronic care.

Patients with chronic conditions may have different physical needs and comfort levels that prevent them from following their care plan and managing their health. Digital technology can offer patients an easier way to access care and stay engaged, help healthcare teams identify gaps in care, and enable healthcare organizations to deliver the highest quality care every time. patient.


Health Catalyst Editors is a team of editors and writers at Health Catalyst offering extensive industry knowledge and experience.

This blog, written by Health Catalyst, previously appeared here.