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7 Challenges in Delivering High-Quality Care to Patients with Chronic Conditions

According to the CDC, 90% of the nation’s $4.1 trillion annual healthcare expenditures are for patients with chronic and mental health conditions. The Milken Institute also reported that chronic conditions and their respective productivity losses cost the U.S. economy over $1 trillion annually. Delivering high-quality care to chronically ill patients has never been more pressing. 

However, managing chronic conditions presents a unique set of challenges for healthcare providers. Chronic conditions require providers to make ongoing investments in patient education, care coordination, and preventive care. Chronic conditions also require patients to become activated in the self-management of their conditions, alter lifestyle and dietary habits, and adhere to medications, tests, and screenings.

Chronic Care Management (CCM) assists healthcare providers in overcoming obstacles and delivering high-quality, comprehensive care to Medicare patients with chronic conditions. Additionally, CCM aids practices in maximizing their revenue through value-based care. 

In this article, we will explore common healthcare challenges presented by chronic conditions and offer solutions to help your practice overcome these obstacles.

Healthcare challenges in Chronic Care Management

1. Managing CCM with insufficient time and resources 

Physicians handling high patient loads are tasked with keeping patient wait time down while ensuring each visit is comprehensive in scope. Healthcare providers can find it difficult to adequately assess and address gaps in care under such constraints. When patients are already managing chronic conditions, their appointments are likely to be heavily focused on their existing health concerns. This can make planning and incorporating preventative care even more challenging.

Learn more: The benefits of Annual Wellness Visits.

2. Engaging, educating, and activating patients

Treatment for chronic illnesses requires a prolonged investment from patients and providers. Patients who are educated about their conditions and engaged with their care are more likely to maintain their treatment plan, adhere to medications, and follow up on preventative screenings and tests. This results in more positive clinical outcomes for these patients, a higher quality of life, and a reduction in expensive procedures and hospitalizations. 

However, for some patients, chronic conditions can be overwhelming and dispiriting. Patients with low health literacy may possess a reduced capacity to process basic health information and make appropriate decisions. 

Preventative care and early-onset detection are enormously beneficial to chronically ill patients, but disengaged patients are less likely to take proactive health measures. This can cause them to lose progress in managing their conditions and allows undetected diseases to worsen. Patient education and activation are time-consuming and must extend beyond the walls of your practice to be effective. 

Learn more: What to expect from a Chronic Care Management program.

3. Gaps in care created by a lack of care coordination 

Patients with chronic conditions are at higher risk of receiving poor care coordination than the general population. Their care is often divided between their primary care provider and various specialists working across different healthcare organizations. 

When a patient’s medical information is not properly collected and distributed throughout their care network, gaps in care arise. Primary care providers may not receive lab results from specialists, leading to an incomplete picture of the patient’s health. As a result, patients may undergo redundant or unnecessary testing, face adverse drug interactions, and experience higher healthcare costs.

Learn more: How care coordination creates positive patient outcomes. 

4. Patients struggling to implement lifestyle changes 

Patients with chronic conditions are often asked to undergo lifestyle changes and exercise regularly to promote physical and mental health. Chronic diseases like high blood pressure and diabetes and associated risk factors like smoking, physical inactivity, and obesity all require patients to alter their habits to improve their health prospects. However, breaking habits and instituting positive lifestyle changes can be challenging for patients. 

Patients may encounter serious physical deterrents that dissuade them from exercising, like chronic pain, fatigue, and limited mobility. Others are hesitant to exercise for fear of exacerbating their symptoms or causing injury. Additionally, the dietary choices made by patients are often influenced by the affordability and accessibility of healthy food options in their homes, workplaces, and communities. 

Building healthy habits takes time, consistency, and positive reinforcement. Healthcare providers don’t always have the time or resources to regularly check in with patients and follow up on their adherence to recommended lifestyle changes. 

5. Patients lacking emotional and psychological support 

Loneliness has devastating consequences on physical health. A precursor to anxiety and depression, loneliness is a biophysical stressor that’s linked to chronic illness, as well as overall morbidity and mortality rates. Depression, anxiety, and stress can cause patients to give up on treatment plans or succumb to unhealthy behaviors that exacerbate their conditions. Loneliness also acutely affects elderly populations, who are more likely to live alone and battle chronic illnesses. 

Learn more: How Chronic Care Management helps patients suffering from loneliness.

6. Practices unable to implement in-house CCM programs

Chronic Care Management programs have transformative implications for your practice, both in terms of improved clinical outcomes and additional revenue streams. But many practices struggle and fail to implement the programs on their own. CCM demands a massive investment of time, resources, and labor. 

From enrolling patients and managing patient churn to recording calls for quality assurance and auditing, the infrastructure needed to support a CCM program can quickly overwhelm practices. Without automated workflows that tackle CCM billing or a team of clinicians capable of making the required 20-minute monthly calls to patients at high volume, practices may struggle to see any financial benefit from implementation. 

Learn more: The ultimate provider’s guide to implementing CCM.

7. Limited resources in remote locations and for underserved populations 

Rural Health Clinics (RHCs) and Federally Qualified Health Clinics (FQHCs) often lack easy access to specialized care and may struggle with healthcare provider shortages, hampering their ability to manage complex chronic conditions and coordinate comprehensive care. 

Technological limitations in remote areas can hinder the adoption of digital tools essential for remote patient monitoring and telehealth services, while socioeconomic factors like lower income levels and transportation difficulties can impact patient engagement and adherence to treatment plans.

Navigating reimbursement processes and allocating resources for CCM services can also be challenging within these budget-constrained environments. To effectively address these challenges, RHCs and FQHCs require tailored strategies that encompass telehealth solutions, improved care coordination, culturally sensitive patient education, and collaboration with community resources to mitigate socioeconomic barriers.

Learn more: The Importance of Chronic Care Management for RHCs and FQHCs

How ChartSpan can help you overcome common healthcare challenges 

At ChartSpan, we address the healthcare challenges of Chronic Care Management (CCM) by enhancing patient care, improving patient engagement, and streamlining practice workflows. Here are a few of the ways we can assist your practice.

Full-service Chronic Care Management 

With ChartSpan’s CCM program, every patient enrolled receives a call from our dedicated care team once a month. Through this regular cadence of contact, our care team reinforces patient engagement and continues to educate patients on their conditions and upcoming medical screenings and procedures. 

Our care management team listens for indications of loneliness or depression and can administer clinical depression screenings (PHQ-2), which are included in the patient summary given to care providers. Enrolled patients also have access to a 24/7 nurse care hotline, giving patients around-the-clock access to healthcare professionals. 

RapidAWV™ with user-friendly Health Risk Assessments (HRAs)

Our RapidAWV™ software delivers user-friendly HRAs to eligible Medicare patients during their waiting room visits. These assessments generate actionable health plans, aiding your practice in addressing risk factors and care gaps. Integration with Electronic Health Records (EHR) ensures a seamless workflow, maximizing each patient encounter. 

Implementing AWVs increases revenue through reimbursements, drives up quality scores for programs like MIPS and ACO, and reduces healthcare costs for patients by 5.7%. You can earn anywhere from $118-$174 in reimbursements per AWV.  

Learn what is and is not covered by Medicare during an Annual Wellness Visit.

Remote Patient Monitoring (RPM) Enrollment as a Service

ChartSpan offers a unique solution to this problem through our RPM Enrollment as a Service (EaaS). Our team of skilled enrollment specialists determines and verifies patient eligibility, acquires patient consent, educates patients, and enrolls them in your RPM program. 

Expanding the scope of your RPM offering lets your practice catch abnormalities in patient data early and plan interventions accordingly. For patients with chronic conditions, this proactive care can have transformational implications for their long-term health and quality of life.

CCM support for RHCs and FQHCs

ChartSpan's CCM services for RHCs and FQHCs offer a streamlined method to manage patient care effectively, relieving healthcare providers from outreach, enrollment, and administrative tasks. This solution enables clinical staff to concentrate on delivering medical treatments. 

Our CCM program ensures adherence to care plans, aids in medication refills, addresses social determinants of health, connects patients to home health care assistance, sets appointments with primary care and specialists, offers caregiver support resources, and facilitates access to test results and imaging for patients in rural and underserved areas.

With each of our solutions, it’s our goal to empower you to deliver high-quality care that results in improved patient outcomes and practice efficiency.

You may also like: Quality Improvement: Processes & Best Practices in Healthcare

Partner with ChartSpan and overcome challenges presented by chronic conditions

At ChartSpan, we have a multitude of resources to help your practice better deliver high-quality care to patients managing chronic conditions. From our turnkey CCM program that engages patients in their healthcare journey every month to our AWV software that maximizes patients’ office visits, we have solutions for the challenges your practice faces. Together, we can help your practice deliver effective care to patients with chronic conditions.

Contact us and learn more about how we can help transform the care your practice provides.

You may also like: 

• The Chronic Care Model Explained
• 10 Myths About Running a CCM Program
• Saas vs. Fully-Managed CCM
• The Most Common Chronic Diseases and How to Manage Them with CCM