Patient Behavior: Improving the Last Mile in Chronic Care

Reaching out to underinsured patients, populations in remote areas, and promoting behavioral change in the population has often been referred to as “the last mile” in healthcare. These patient behavior factors are essential in closing the gap in care available to chronic care patients, as numerous studies have indicated that greater access to health insurance, in and of itself, is not sufficient to improve outcomes in those patients.

The CDC (Centers for Disease Control) has reported that the treatment of chronic diseases accounts for 75 percent of healthcare costs. Lack of condition maintenance leads to poor medication adherence rates that result in more costly care. Improving medication adherence rates alone could eliminate $105.4 billion in avoidable costs (based on IMS Institute of Health Informatics Data).

Chronic Care Management (CCM) program that has been implemented by Center for Medicare and Medicaid Services (CMS) as of 2015 allows for additional clinical support and patient management outside the clinical setting. The program allows providers to bill $42.60 per patient/per month for 20 minutes of non-face-to-face time offered to qualified patients. Patients must have two or more chronic conditions likely to last for at least 12 months or until the death of the patient and, and that if untreated will lead to functional decline.

The use of a systems platform that addresses all requirements outlined by CMS would allow the provider to monitor the patient with chronic conditions and provide a wide range of data to monitor the patient’s condition. The multilevel systems platform allows the provider to interact with the patient as well as share the relevant data with all parties involved in patient care to create a streamlined approach patient monitoring, which would improve adherence and create an ongoing real-time interaction among the care team. This type of systems platform technology promotes adherence and cuts costs while offering improved care management to the patient population.

P5 Connect, Inc. is a services company that is focused on creating custom-built programs that allow each provider to use patient-specific and disease-specific clinical programs to monitor the patients. The clinical programs and data access allow P5 Connect, Inc. to work with each unique provider and their unique pool of patients to identify additional support needed to manage a particular patient population. Continued access to the patient profile by the entire treatment team allows for ongoing monitoring of patient’s behavior. Over time, continued monitoring of patients’ behavior will allow the care team to understand which patients responded to which interventions. This information will in-turn lead to more informed decisions when deciding which interventions will lead to better outcomes.

Unique clinical programs created by the P5 Connect, Inc. team enables targeted outreach to specific patients at the optimal time for each of the unique patients in the system’s database. This allows for ongoing, targeted management of each patient’s condition through systematic outreach to the patient and ongoing secure data sharing among each patient’s care team. In today’s healthcare landscape, patients need ongoing support outside the clinical setting to effect the necessary behavior change. Patients trying to manage complex chronic conditions need uninterrupted access to the care team as well as access to educational information that may be necessary to properly address the disease state that the patient is managing.

A systems platform that combines analytics, data management, unique stratification, custom built clinical programs, and real-time interaction with the patient’s care team regardless of the patient’s location, is likely to engage the patient in a way that will affect behavior change necessary to improve outcomes and, thereby, reduce the costs of healthcare.