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The Challenges of Managing Patients with Multiple Chronic Conditions

The prevalence of multiple chronic conditions among the American population is one of the defining challenges in contemporary healthcare. In research conducted by the National Center for Health Statistics (NCHS) in 2018, over 27% of adults in the United States had two or more diagnosed chronic conditions. Owing to the study's limitations, the NCHS believes the actual number could be even higher than what their reporting found.

The likelihood of patients suffering multiple chronic conditions increases with age, as 62% of Americans over the age of 65 are diagnosed with more than one chronic condition. With the aging of the American population, the number of patients presenting multiple chronic conditions (also referred to as MCCs) will continue to strain healthcare resources if not managed effectively and strategically.

In this article, we will explore some of the biggest challenges that multiple chronic conditions present to patients and healthcare providers. We also discuss how patient-centered care can help reframe the complex conversation surrounding chronic illness management and how services like Chronic Care Management can help your practice transform the quality of care delivered to patients with multiple chronic conditions.

Why are multiple chronic conditions a concern?

Due to their complexity and requirement for ongoing treatment, chronic conditions are associated with higher resource use, more frequent hospitalizations, and more expensive healthcare costs for patients and healthcare systems alike. This contributes to patient fatigue and depression, further exacerbating and complicating care delivery and intervention.

Some chronic conditions are also more likely to present in unison. When aggregated, these conditions can create more significant health risks for the patient. For example, diabetes, high blood pressure, and high cholesterol are commonly seen together in patients. If poorly managed, these conditions could exacerbate one another and lead to serious and life-threatening heart conditions, like coronary heart disease and congestive heart failure.

Patients can mitigate these conditions and associated risks through preventative care and proactive wellness planning. But when they are left undiagnosed and untreated, multiple chronic conditions will coalesce into greater health problems.

Furthermore, patients with multiple diverse chronic conditions present entirely different problems. If a patient has dementia in addition to diabetes, their nutrition and exercise care plans may suffer as their mental capacity deteriorates. A patient battling depression who is also diagnosed with cancer may discontinue medications, treatments, or follow-up appointments because of lethargy or hopelessness associated with the mental illness.

An oncologist is not as well-equipped to manage depression as a trained mental health professional, and they can only provide treatment plans for the condition within their expertise. Suppose the patient suffers from disjointed or poorly coordinated care or only receives care for some chronic conditions. In that case, improperly coordinated care further compromises their health and impacts their other conditions.

5 challenges of managing patients with multiple chronic conditions

Multiple chronic conditions require complex treatment plans

Every patient's healthcare journey is distinctive and defined by unique risks, conditions, lifestyles, and personal preferences. When a patient battles multiple chronic illnesses, their treatment plans become increasingly complex.

A patient managing type 2 diabetes and chronic kidney disease needs to simultaneously manage multiple medications, lifestyle adjustments, and a diverse schedule of medical appointments and screening. This can be difficult for patients and practices to maintain, especially if the patient has low health literacy or the provider has limited resources.

More complex treatment plans carry a greater risk of non-adherence and subsequent damaging consequences among patients who are not activated and engaged in their care. The inherent complexity of managing MCCs can also lead to poor care coordination, adverse drug interactions, frequent hospital utilization, redundant testing, and decreased quality of life for the individual patient.

When patients are diagnosed with multiple chronic conditions, it is critical that their healthcare providers actively engage them and encourage them to seek preventative care. Involved patients are more likely to take proactive measures and ultimately see better clinical outcomes. Patients balancing multiple chronic conditions should be taught to effectively self-manage their illnesses and instilled with the confidence to navigate the complexities of their treatment plans.

Preventative care planning also enormously benefits patients with multiple chronic conditions. Medicare’s Annual Wellness Visit (AWV) program helps providers create manageable, personalized care plans that encourage patients to engage with their care journey proactively.

Learn more: The Ultimate Guide to Medicare Annual Wellness Visits

Lack of care coordination creates gaps in care

Patients with multiple chronic conditions often consult numerous healthcare providers and specialists across several healthcare networks and organizations. Critical patient information can be lost between providers without intentional communication and well-facilitated care coordination.

Studies have shown that patients with chronic conditions are more likely to receive fragmented and poorly coordinated care. This creates gaps in care in the patient’s health journey, compromising their health and driving up their treatment costs.

Patients suffering from poorly coordinated care may receive conflicting treatment recommendations from different providers, elevating patient confusion and frustration. This can lead to them abandoning medications, appointments, and treatment plans, causing their conditions to deteriorate further.

They may also receive duplicated or superfluous testing if practices do not communicate, which causes them greater expense and wastes their time. Poor care coordination can also create complications for patients. Patients with MCCs are likely to be on multiple medications. If a provider places them on a new medication without checking for any negative interactions with their current medications, a patient can suffer undesirable or even dangerous side effects.

Coordinating care for patients with multiple chronic conditions is time-consuming and requires strategic focus and communication. These are precious and rare resources, and MCCs place heightened pressure on already overburned and understaffed healthcare systems. Care managers, like those provided by Chronic Care Management companies, help alleviate this strain. Care managers can assist practices by requesting records from providers and specialists and building a unified care plan for an individual patient.

Unaddressed SDOHs undermine treatment plans

Social Determinants of Health (SDOHs) can dramatically affect patients' health. A patient’s health does not exist in a vacuum. It is informed by the community surrounding a patient and their own set of socioeconomic and geographic factors.

Patients without reliable transportation access are more likely to miss critical appointments or fail to pick up medications from their pharmacy. Patients struggling to afford rent may eliminate medical expenses from their budget to keep themselves safely housed. Patients in food deserts or with low incomes can find it challenging to implement the healthy, nutritious diets advised in their treatment plans. Uninsured or underinsured patients may avoid seeking medical care because of the costs.

If providers are unaware of their patients' social challenges, they cannot intervene and assist. Many practices are already overwhelmed by their current workloads and devote their focus to treating patients’ physical ailments. This means SDOHs can go unaddressed, and patients may ultimately discontinue treatments.

A steady cadence of communication between patients and their healthcare providers builds trust. It also allows patients to express the social and economic challenges they are experiencing in real time.

When a patient has monthly access to a care manager through a program like Chronic Care Management (CCM), the care manager can assist them with transportation, medication delivery, or food and housing assistance as soon as they learn of the patient’s precarious status. This eliminates the gap in care before it’s created, helps keep the patient adherent to their wellness plan, and elevates the patient's quality of care.

Learn more: How CCM Programs Improve Access to Care

Multiple chronic conditions place a psychological strain on patients

Living with a chronic illness is physically, mentally, and emotionally challenging for patients. Chronic conditions often require rigorous medication regimens and specialized diets. They can be accompanied by limited mobility, recurring pain, and sleep interference. These factors alone can place a heavy psychological strain on patients and lead to exhaustion and despair. If a patient has a behavioral health condition, like anxiety or depression, the added stress of MCCs can further intensify these illnesses.

Research demonstrates that chronic conditions can also be isolating. Patients who are depressed or fatigued from their extensive treatments may socially withdraw. Loneliness is proven to have a detrimental impact on a patient’s health. Patients with multiple chronic conditions are significantly at risk for social disconnection and the physical and mental health risks associated with loneliness, especially as they age.

Ensuring that patients with multiple chronic conditions have access to behavioral health care and have some community connection or social stimulation is challenging, as it requires investment in patients' lives beyond the walls of your practice. However, it is critical for a patient’s well-being and clinical prospects that they can access emotional relief and socialization despite the difficult health circumstances they face.

Programs like Integrated Behavioral Health Care (IBHC) interlace mental healthcare with patient primary care, making mental health services more accessible. Care management services like CCM provide patients with around-the-clock assistance through 24/7/365 nurse care lines and monthly calls from care managers. These calls can help offset patient loneliness, facilitate mental health interventions, and ensure no patient is ever isolated in their healthcare journey.

Learn more: 5 Reasons to Offer Integrated Behavioral Health Services

Practices have limited staff, time, and resources available

Patients with multiple chronic conditions require a significant devotion of time and resources. Many providers are already overwhelmed with high patient loads and the pressure to minimize wait times. The clinical staff at practices often face daunting workloads, from submitting medication refills to submitting insurance claims on behalf of patients. The level of personalized investment that MCCs require can stretch the precious, limited resources available at these already overburdened practices.

Incorporating new programs, like AWVs or an in-house Chronic Care Management program, can feel impossible, regardless of its benefits to providers and patients. However, full-service, turnkey CCM companies like ChartSpan are ideal partners in these ventures.

ChartSpan can partner with you as an extension of your practice without requiring lengthy extraneous training or the hiring of additional staff. We have the telephonic and data analytic infrastructure in place to assist with eligibility, enrollment, churn, documentation, and billing. This allows your practice to continue operating within established workflows while reaping CCM’s benefits.

Learn more: Chronic Care Management: A Guide for Providers

Patient-centered care: a solution to the challenges of multiple chronic conditions

Patient-centered care is a healthcare strategy that aims to improve healthcare quality and clinical outcomes by focusing on the patient in all medical decisions. The patient-centered care model emphasizes building relationships between patients and providers to establish trust and strengthen patient confidence.

Patient-centered care encompasses a broader view of the patient, including their lifestyle, personal beliefs and preferences, community, and background. Treatment plans are thoughtfully customized to each patient’s unique medical history, chronic conditions, and personal values.

When a patient manages multiple chronic conditions, patient-centered care is one of the most effective ways to deliver quality care. The complexity of MCCs can leave patients feeling isolated or overwhelmed, but patient-centered care prioritizes the individual and their unique preferences and goals.

This care strategy engages patients in decision-making and care planning, empowering them as collaborators in their healthcare journey. Patients with multiple chronic conditions often face complex and arduous paths toward optimal health, so activating them in their care is critical to long-term success.

Patient-centered care also fosters stronger communication between patients and their providers by increasing the frequency and depth of communication. This encourages improved treatment adherence and shared decision-making. This model also promotes care coordination among multidisciplinary teams, reducing the friction often encountered by patients with MCCs.

Ultimately, patient-centered care promotes a comprehensive approach to managing complex health issues and addressing the diverse physical, emotional, and social aspects of managing multiple chronic conditions.

Partner with ChartSpan and deliver high-quality, patient-centered care

ChartSpan is a national leader in innovative healthcare services. We emphasize patient-centered, high-quality care and rewarding, seamless partnerships with practices and healthcare providers.

We offer RapidAWV™, a proprietary, flexible AWV software designed to painlessly and effectively implement AWVs into any practice. The software is highly customizable and dynamic, allowing you to craft HRAs specific to your patient population. Our RapidAWVs™ furnish providers with detailed summaries of individual patients’ lifestyle risk factors, familial medical history, and gaps in care. Using this, providers can craft highly personalized care plans for each patient with confidence and ease.

Through our fully managed CCM program, we help practices deliver extraordinary care to patients with multiple chronic conditions daily.

How ChartSpan’s Chronic Care Management benefits patients with multiple chronic conditions

1. Monthly calls with care managers

ChartSpan’s care managers provide every enrolled patient with a monthly touchpoint to reflect on their health, treatment plan, and personal challenges. This provides critical intervention points throughout the year and keeps patients activated in their care between clinical visits.

ChartSpan’s compassionate and knowledgeable care managers are trained to provide patients with self-management tips, educational materials, printed collateral, and access to community resources and transportation, among many other services. If they notice signs of mental health distress, they can administer clinical depression screenings (PHQ-2s) and share the results with the patient’s primary healthcare provider.

2. SDOH assistance and intervention

Care managers can identify and address SDOHs that may interfere with a patient’s health journey. They can arrange medication delivery, transportation to and from appointments, screenings, and vaccinations, and offer resources for social groups and socioeconomic assistance. These interventions have transformative effects on patients' physical and mental health and help foster a sense of trust and loyalty between patients and your practice.

3. Access to 24/7/365 nurse care line

ChartSpan offers a year-round, 24-hour care line for all patients enrolled in the CCM program. This provides patients with MCCs with a trustworthy resource with unlimited access. No matter the time, day, or challenges, enrolled patients can consult with trained professionals to assist them with the care plans prescribed by your practice.

4. Care coordination

ChartSpan can remedy the often fragmented care coordination patients with multiple chronic conditions face. ChartSpan representatives can contact practices and request the results of screenings, blood work, and lab tests on behalf of the patient. They can ensure that all healthcare providers involved in the care access the most updated and holistic information on a patient’s health journey.

5. Fully-managed CCM offsets practice workload

For practices hesitant to implement CCM because of the daunting amount of labor involved, ChartSpan’s turnkey CCM service is an ideal solution. We have many years of experience across primary care facilities, specialty practices, and hospitals. We also provide all the required labor to provide patient outreach and ongoing communication, preserve the rigorous documentation required by CMS, and ensure that we are always available for your staff to consult with any questions that may arise.

Contact us and learn more about how our CCM services can help solve the challenges presented by patients with multiple chronic conditions.