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Managing Multiple Chronic Conditions: A Guide to Patient Care

Patients with multiple chronic conditions (MCCs) are on the rise. An aging population, lifestyle trends, and socioeconomic challenges have all contributed to increased rates of chronic conditions. Today, 42 percent of American adults have two or more chronic conditions. 

For healthcare providers, the prevalence of MCCs poses a serious hurdle. Caring for patients with multiple chronic conditions is complex, requiring significant care coordination. Treating MCCs also strain the healthcare system. Patients in this group are frequent healthcare users and contribute to a disproportionate share of acute care visits.

At the same time, patients suffering from multiple chronic conditions face an increased risk of mortality and accelerated rates of decline. Of the top ten causes of death, half are strongly linked to treatable, preventable chronic diseases. Due to the complexity of their care, patients with MCCs often experience medication and care plan misalignment, resulting in lower adherence to provider instructions and gaps in care. 

For all these reasons, providers must adopt strategic, sustainable solutions to support patients with MCCs. In this article, we will explore the pervasive nature of chronic conditions, how MCCs affect healthcare providers and patients, and ways to better care for this growing population. We will also discuss how adopting a care management model can help your practice improve outcomes for patients with multiple chronic conditions. 

The prevalence of multiple chronic conditions

More and more American adults have multiple chronic conditions, also referred to as multimorbidity. According to the Centers for Disease Control and Prevention (CDC), an estimated 129 million Americans suffer from at least one major chronic disease.

Chronic conditions include a broad range of ongoing health concerns that contribute to mental and physical decline. Common examples include hypertension, diabetes, chronic obstructive pulmonary disorder (COPD), and chronic depression, among others. Developing one chronic condition often puts patients at risk of developing another. In 2018, more than half of American adults had at least one chronic condition and nearly 30 percent had two or more. 

Experts point to several key factors when explaining the prevalence of multimorbidity. Some sociodemographic and economic factors put patients at higher risk of developing multiple chronic conditions. For example, chronic illness is more common among certain groups, including women, non-Hispanic white adults, older adults, and those in rural areas. 

There’s also a strong link between geography and incidence of chronic disease. People living in ZIP codes with lower median home values, poor healthcare access, and lack of community infrastructure tend to experience higher rates of chronic illness. 

Because MCCs have a basis in both medical and non-medical risk factors, effective care requires a holistic approach. Patient-centered treatment must consider Social Determinants of Health (SDOH), like transportation and healthcare access, in addition to other elements of care planning such as medication, nutrition, and exercise. CCM offers a satisfying answer for providers seeking solutions for MCC care. 

The effect of multiple chronic conditions on healthcare practices

For providers, managing multiple chronic conditions is a multi-dimensional challenge. Effective care is resource-intensive, requiring significant time, money, and multi-specialty collaboration.

Increased complexity

Research and academia tend to examine a single disease in isolation. Today’s providers, however, cannot silo their treatment in such a way. Instead, larger caseloads of patients with MCCs require physicians to navigate greater care complexity. 

Clinicians must adopt a broader perspective of the patient’s health, communicate with other providers, and manage medications carefully. Coordinated care methods, like Advanced Primary Care Management (APCM) for primary care providers or Chronic Care Management (CCM) for a variety of providers, support this kind of complex treatment planning. A collaborative approach helps providers deliver effective treatment that minimizes gaps in care and improves patient experiences.

Financial and administrative strain

The prevalence of chronic disease has placed a tremendous strain on the American healthcare system. Managing multimorbidity is costly for both healthcare practices and patients. Of the nation’s $4.5 trillion annual healthcare expenditures, 90% can be attributed to caring for patients with chronic and mental health conditions. 

MCCs also present a related administrative burden on healthcare providers, requiring extensive insurance documentation and billing. Practices that care for patients living with multiple chronic conditions must adopt solutions for streamlining documentation and reimbursement processes. Implementing a care management program through a provider like ChartSpan can relieve the stress on already-taxed practice staff with clear, defensible billing documentation aligned to the Centers for Medicare & Medicaid Services (CMS) reimbursement requirements. 

Care management programs are healthcare frameworks devised by CMS to support Medicare beneficiaries, most of whom have chronic diseases. Core components include patient access to a 24/7/365 care support line, personalized care plans, and self-management, among other preventative care-based features. 

Higher care utilization

Given the complexity and interconnected nature of chronic illnesses, MCCs account for a large portion of both preventive and acute care needs. An overwhelming majority of hospital readmissions among Medicare beneficiaries occur among patients living with MCCs. Likewise, 70 percent of all inpatient stays are attributed to patients with multiple comorbidities. 

Illness-focused acute care models cannot sufficiently support patients' needs across the care continuum. Clinicians in various care settings and specialties must collaborate on patient care. Chronic comorbidities and the associated high demand for healthcare services underscore the need for innovative solutions, including healthcare technologies like electronic health records (EHRs) and remote care. 

The effects of multiple chronic conditions on patients

Patients with multiple chronic diseases often face difficulty navigating the healthcare system. Countless appointments, consults, lab tests, and clinical treatments place undue burden on multimorbidity patients and can interfere with the efficacy of their care plans. 

Risk of redundant treatment 

The healthcare community has long recognized the importance of moving away from a reactive, disease-focused model of care to a more collaborative and preventative model. Still, patients with complex care needs, like those with MCCs, often experience care redundancy. 

Duplicate screening and consults or unnecessary testing remain a symptom of fragmented care. For example, a provider might order blood work without checking to see whether the patient recently underwent similar labs. Patient-centered care, supported by technology and focused on care coordination, helps alleviate these issues. 

Significant time and financial expenditure 

Managing multiple chronic conditions is costly for patients, especially when considering that MCCs affect rural, economically disadvantaged, and older Americans at higher rates. These patients already have limited resources, so the impact of MCCs can be more detrimental. 

Appointments, tests, and scans require a substantial time commitment. And, for patients with less access to care and transportation, showing up for appointments can be burdensome. 

Treatment for multiple chronic conditions is also expensive. Out-of-pocket fees for testing and treatment add up quickly. Medication side effects, symptoms of chronic illness, and frequent appointments also can result in missed work time or difficulty sustaining a job. 

Functional and emotional decline

Many patients with chronic disease suffer profound physical and emotional hardship. For example, patients with MCCs often experience physical decline such as mobility issues and difficulty completing day-to-day tasks like eating, driving, or cooking. Pain, insomnia, and fatigue are also common side effects of many chronic diseases.

In addition to the physical impact of chronic illness, many patients also experience severe mental and emotional strain, sometimes as a result of functional decline. Isolation, due to decreased ability and mobility, can feed loneliness, anxiety, and depression.

For some patients, the mental and physical toll of MCCs also inhibits adherence to care plans and medication regimens. A patient with hypertension, for example, might be directed to keep up a healthy exercise and nutrition routine. However, if the patient also struggles with chronic depression, persistent feelings of hopelessness and lethargy might make it difficult to maintain the habit. 

An integrated care approach, like care management, can help. Effective, patient-centered care expands the lens of support beyond physical health. In many cases, it considers behavioral health and SDOH, as well. In this way, care management offers an ideal framework for managing MCCs. 

How to care for patients with multiple chronic conditions

Caring for patients with multiple comorbidities requires a multilayered approach. By implementing a care management program, providers can support optimal patient outcomes. 

The power of care management programs

Managing patients with multiple chronic conditions requires a structured, continuous approach. Care management programs provide this essential framework by ensuring that patients with two or more chronic conditions receive ongoing support beyond in-office visits. Chronic Care Management (CCM) focuses on Medicare patients with chronic conditions, offering regular monitoring, personalized care planning, and ongoing communication to improve health outcomes and reduce hospitalizations. Advanced Primary Care Management (APCM) builds on this foundation by incorporating a more comprehensive, whole-person approach to patient care, integrating preventive services, behavioral health support, and enhanced coordination across healthcare providers.

ChartSpan provides full-service care management support, helping practices implement and manage programs like CCM efficiently and without administrative strain. From patient outreach and enrollment to ongoing communication, care planning, and 24/7 care line support, ChartSpan ensures that patients receive continuous, high-quality care. By streamlining care management operations, practices can enhance patient engagement, improve health outcomes, and focus more on in-office patient care while ensuring patients receive the support they need beyond visits.

1. Patient-centered care plans 

Supporting patients with MCCs requires personalized care that considers the patient’s entire picture of health. An effective care plan is collaborative, involving input from relevant specialists. It’s also comprehensive, including lifestyle factors such as diet and exercise. ChartSpan works with patients to ensure care plans match patient goals and needs. If changes arise, ChartSpan communicates the developments back to providers, who can then adjust the plans. 

2. Provider record coordination 

Often, there are specialists involved in caring for patients with multiple chronic conditions. For example, a patient with kidney disease and heart disease likely sees both a nephrologist and a cardiologist in addition to primary care doctors. Care management ensures that all providers involved in a patient’s care are aware of the patient’s health history, existing treatments, and medications. This approach reduces overlapping treatment, prevents gaps in care, and improves the patient’s experience navigating the healthcare system. 

3. Behavioral health support 

Patients with multiple chronic diseases have a heightened risk of developing mental health conditions, such as loneliness, anxiety, and depression. Similarly, chronic depression and many chronic illnesses are comorbid, meaning they are often present at the same time. The presence of one can worsen the other. For this reason, behavioral health support is a vital component of effective care for patients with MCCs. Incorporating the expertise of mental health professionals ensures patients receive comprehensive, holistic care. 

4. Community-based interventions

Family, friends, and community resources play a vital role in supporting patients with MCCs. Care plans, like those developed as part of an APCM or CCM program, can include community services as part of a holistic approach to health. This broader view of an individual’s health improves long-term wellness, and in many cases, helps to address the cause of illnesses, rather than the symptoms. 

5. Patient education 

Empowered patients have the knowledge and confidence to speak up about health concerns, notice key changes to their conditions, and manage their own conditions between incidents of care. To this end, ChartSpan ensures patients enrolled in its care management programs receive ongoing education to encourage patient self-management. 

6. Digital communication 

Caring for patients with multiple chronic conditions requires an emphasis on proactive, accessible communication. By leveraging digital health technology, including electronic health records (EHRs), remote check-ins, telephonic software, and digital surveys, texts, and emails, providers can ensure an open line of communication with patients. 

24/7/365 access to care is a required component of both APCM and CCM. Patients also have a dedicated care manager, in addition to the around-the-clock care line, to support attentive communication and foster strong support. 

Advanced Primary Care Management vs. Chronic Care Management

For patients with multiple comorbidities, care managers serve as patient advocates and the “glue” of the care team. Adopting the right care management program makes a patient-centered approach to MCCs—including all the elements listed above—straightforward and consistent. 

For physicians who are the primary point of care, implementing an APCM program may offer the best fit. The more flexible nature of APCM is well-suited to providers who are already familiar with care management, while CCM offers a more clearly structured framework. 

The two programs are similar in many ways; however, APCM has a great emphasis on flexible digital communication and care transitions and is available to all Medicare patients. CCM requires 20 minutes of consistent monthly clinical work from a care manager and is only available to those with two or more chronic conditions. 

ChartSpan can help you decide which care management program is a better fit for your practice.

Learn more: The Provider’s Guide to Advanced Primary Care Management

How care management improves outcomes for patients with multiple chronic conditions

The care management model provides an answer to the complexity of managing multiple chronic conditions. Here is how care management yields better outcomes for this unique patient population. 

• Patient-centered care: Care management requires the creation of a personalized care plan. An individualized plan recognizes the entire person, including factors such as the patient’s cultural background, personal values, and Social Determinants of Health in addition to more conventional medical goals. This comprehensive care management exercise, which is constantly reassessed as patient needs change, helps to minimize gaps in care and put patients on an achievable health trajectory, ultimately improving outcomes.
• Fewer acute care incidents: By partnering with a care management organization like ChartSpan, providers gain the tools to support a truly preventative care approach. Features like care plans, regular patient check-ins, and a framework for patient self-management help identify health issues before they become acute and reduce patients’ reliance on hospital care. This proactive model prevents complications and improves patients’ quality of life. 
• Increased patient engagement: Care management encourages patients to become active participants in their care. ChartSpan supports self-monitoring, assesses any changes needed to care plans, empowers patients with ongoing education, and connects them to both medical and non-medical support resources—all of which boosts patient engagement. These engaged patients are more likely to take medicine as prescribed and adhere to clinical recommendations, improving their health outcomes. 

Overcome the challenges of managing patients with MCCs with ChartSpan

Helping patients achieve health when multiple comorbidities are present isn’t easy. Partnering with a care management provider like ChartSpan offers a critical solution for tackling this prevalent, high-stakes phenomenon. 

To learn more about ChartSpan and how we help practices like yours better support patients with MCCs, contact us to talk to an expert. We take the heavy lifting of implementing a patient-centric care management program off your plate for better quality care and better patient outcomes. 

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