By Simon Trussler
10% of the US population accounts for more than three-fifths of US health care expenditures and these are largely tied to chronic conditions (including heart disease, lung disease, cancer, and diabetes). 3 in 4 people aged 65 years or older have multiple chronic conditions and account for 93% of prescriptions and nearly 80% of physician visits and hospital stays. Elderly and disabled patients living at home create special challenges for the health system, particularly those in remote rural areas.
We need a way to more effectively manage the care of these patients, especially those that are at high risk of adverse health trends and hospitalization. In-home monitoring and self-management support has the potential to augment traditional complex care management approaches and significantly decrease the amount of time, money, and stress involved in keeping these patients on the right track.
More often than not, chronically ill patients have multiple doctors, clinicians, and services that their care team must coordinate. This includes primary care as well as specialty clinicians, behavioral health, and social service providers. A platform that brings together all of the elements of each patient’s care plan, together with agreed self-management protocols for common situations, can help these patients better understand their chronic conditions and how to self-manage effectively.
Patient care teams must also be able to rapidly and effectively respond to adverse health trends to avoid costly and stressful emergency visits or hospitalizations. In-home self-management platforms have the ability to capture daily care plan compliance and health status data, enabling continuous monitoring and early intervention to address emerging issues. The data can also be used to identify individual gaps in care and to provide care support team members with rich background information for health coaching calls.
In early trials, patients using these in-home platforms have shown high levels of satisfaction. They find it easier to remember the key tasks in their daily care plan and they better understand when to ask for help. Providers also appreciate the real-time data that provides a clearer picture of population health: which chronic conditions are hardest to manage, which care plan items cause the most compliance issues, and how patient behavior patterns should impact risk stratification. As these approaches are adopted more widely, the in-home self-care approach has the potential to simultaneously address the healthcare “triple aim” goals of cost control, clinical quality, and patient satisfaction.