“IF PATIENTS KNOW MORE, they follow directions better and
get things like blood sugar under control. They can
improve dramatically in just two or three months but
need encouragement to keep up with the regimen.”
A solid PHM plan includes:
• Strong data collection and IT for analysis
• Care management that is cohesive and features
well-managed objectives such as patient compliance
and self-motivation
• The creation of subpopulations around health,
lifestyle and medical history so that providers can
further understand needs and trends
• Complete, comprehensive patient population profiles
to assist with identifying patients at risk for
readmission and to create patient-specific care plans
• Data sets for patient notification, appointments, and
other touchpoint engagements so that patients have a
higher level of engagement, education and participation
in their care.
Conclusion
For all these reasons and more, chronic disease management
is an essential component of any overall population health
management effort. Those engaged say that it often feels
like trying to turn back the tide with a teaspoon, yet they
remain hopeful because they see how well education and
outreach can work alongside comprehensive care strategies.
They also know that things may get worse in the coming
years, as the aging Baby Boomer population crests and
other social forces come into play, and so caregivers are
bracing for that impact.
“The American Diabetes Association puts out standards of
care every year, and recent ones did show a slight decrease in
people being diagnosed,” Sharecare’s Carden says. “We’re
not sure if that’s because of better medication, or people
becoming more knowledgeable about causes and doing a
better job with diet and exercise, but it’s good news. Even
so, the experts are predicting a continual increase with
diabetes and some other conditions over the next few
years, so things may still get pretty bad. We are going
to have a lot to do for these people.”
For more information on HealthStream’s training solutions for population health
and chronic condition management, visit www.healthstream.com/population-health.
References
Beveridge, Roy A. “Chronic Treatment Is Not “One and Done.” February 6, 2018. NEJM Catalyst. Accessed May 14, 2019. https://catalyst.nejm.org/
chronic-conditions-treatment-not-done/
Bresnick, Jennifer. “FDA: Education, Population Health Can Fight Opioid Abuse.” June 1, 2017.Accessed April 7, 2019. https://healthitanalytics.com/
news/fda-education-population-health-can-fight-opioid-abuse.
Bresnick, Jennifer. “Mental Health, Primary Care Integration Cuts Depression Scores.” March 9, 2017. Accessed April 5, 2019. https://healthitanalytics.
com/news/mental-health-primary-care-integration-cuts-depression-scores.
HHS, “Multiple Chronic Conditions: A Framework for Education and Training.” June 2015. Accessed May 14, 2019. https://www.hhs.gov/sites/default/
files/ash/initiatives/mcc/education-and-training/framework-curriculum/framework-curriculum.pdf
Kent, Jessica. “Addressing Chronic Disease with Population Health Management Strategies.” July 12, 2018. Accessed April 8, 2018. https://healthitanalyt-
ics.com/news/addressing-chronic-disease-with-population-health-management-strategies.
NCOA, “Healthy Aging Facts.” Accessed April 7, 2019. https://www.ncoa.org/news/resources-for-reporters/get-the-facts/healthy-aging-facts/.
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