Care Management

Multiple Chronic Conditions: How Technology Can Help Patients Who Need it Most

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One of the biggest challenges of population health management (PHM) involves identifying and helping patients with multiple chronic conditions. MCC, as they’re also known, affect one in four people in the United States, including 75 percent of those 65 and older. They’re also on the rise in countries worldwide, a trend likely due to a host of conspiring factors, from the shift toward more-sedentary (and high-calorie) lifestyles to the rapidly aging global population. As more people are living into their 70s and 80s, their chronic ailments are adding up: It’s no longer “just” diabetes, or heart disease, or cancer—it’s heart disease and diabetes, or it’s cancer and depression, or it’s that person with hypertension, arthritiIt’s s, and dementia who has trouble remembering to take all her medications.

The problem, of course, is that the stacking of chronic conditions one atop the next typically doesn’t bode well for patient outcomes. As numerous studies have pointed out, individuals with MCC often have difficulty with day-to-day functioning and face an increased risk of hospitalization and premature death. And the economic consequences of MCC are just as stark: According to the U.S. Department of Health and Human Services, more than 70 percent of healthcare spending in the United States goes toward the treatment of those with MCC. Dealing with MCC is an expensive proposition—not only in terms of physical and financial costs for individual patients, but also for its impact on healthcare overall.

Innovative MCC Solutions

So are healthcare providers on the leading edge of PHM, where value-based care is the key to success, finding ways to address the chronic-conditions dilemma? And is it even possible for organizations like patient-centered medical homes to both provide effective care for people with MCC and do so in a way that minimizes costs?

The answer in both cases is a resounding yes. Thanks in part to technologies from IBM Watson Health that facilitate patient outreach and support clinical care, a growing number of organizations are developing innovative strategies for tackling the problems people with MCC face head-on.

Watson Health’s various PHM solutions mine clinical and administrative data across an organization’s continuum of care. The technologies give providers insight on specific patient populations so they can devote their clinical resources to the individuals who need it most.

Several of Watson Health’s individual solutions support providers in caring for patients with MCC. For example:

  • The IBM Explorys platform uses data analysis to identify which patients have MCC, or the prevalence of diabetes in a cohort of patients already at risk for other chronic conditions.
  • The IBM Phytel platform helps ensure the provider can see medications a patient is taking as a starting point for medication reconciliation – a critical need for MCC patients – through a pre-visit prep capability. In addition, the campaign functionality in the IBM Phytel platform enables care teams to more effectively manage individuals with MCC and engage with them more frequently.
  • IBM Phytel Outreach uses evidence-based protocols and can be configured to automatically contact and communicate with high-risk patients. IBM Phytel Outreach simplifies and accelerates the patient engagement process, allowing physicians and their teams to focus on providing care.

In the future, these solutions will be able to dive further into the social determinants of health: Is that patient with diabetes living alone? Does she have friends or family who can help her with her medications? Additionally, cognitive computing will enhance the solutions’ abilities to mine data for key insights.

What else does the future hold for patients with MCC? Stay tuned for more posts featuring Watson Health clients who are using our technologies to improve their lives every day.

Global Leader, Population Health Strategy

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