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by Georgia Brown
Published on September 26, 2018

Life expectancy has increased dramatically in the past century as advances in medicine and technology allow adults to live longer and more fulfilling lives. Today, people can live with chronic conditions for many years. The good news is that certain diagnoses no longer carry a death knell.  However, work is still needed to improve the quality of life and the high cost of care during the later years of life. It is estimated that 13 percent of health care dollars are spent during the final year of life. Today, there are 617 million people across the globe who are over the age of 65, representing 8.5 percent of the total population. That number is predicted to rise to 1.6 billion by 2050. Right now, in the United States alone, 10,000 baby boomers turn 65 every day, and the fastest growing age group is 85 and older.   With the increasing senior population comes an increase in chronic disease. Data from the National Council on Aging shows that 91 percent of people over age 65 have at least one chronic condition, and 73 percent have two or more. Over half of those aged 85 and over have at least one Activities of Daily Living (ADL) deficit, and 1 in 6 people have three ADL deficits or more.  In the U.S., 30 million people have diabetes, and another 86 million have prediabetes. The CDC projects that by 2040, one out of every three dollars spent in the Unites States will be on health care.     What does all this information tell us? Essentially, it means that we have a global chronic disease crisis, and our current models are not sustainable.

Increased chronic disease, increased demand on clinicians

With the increasing prevalence of chronic disease comes an increased demand on clinical providers; however, we cannot keep up with the pace. The number of people requiring chronic care management is rising while the number of care providers is falling, and there aren’t enough clinicians to continue providing care the same way. The Association of American Medical Colleges has predicted a shortfall of primary care physicians between 12,000 and 31,000 by 2025. 

In other words, we cannot continue providing care the way we do today. We can no longer operate in disconnected silos or cycles of care that begin and end in the acute care setting and with chronic care management occurring only in acute care facilities.      

Approximately 25 percent of acute facility discharges receive post-acute care in a long-term care facility, independent rehab facility or home health; these are individual silos of care. Nearly 70 percent of acute patients are discharged to the community with no post-acute care at all, which makes for yet another disconnected silo. For patients with chronic disease, this is a cycle of care from acute to post-acute to home and back to acute.

The million-dollar question, then, is tri-fold:

  1. How do we connect all the settings of care, including the home?
  2. How can we shine a dynamic light on the complete risk portrait of a patient?
  3. How can we use care settings and care providers at the appropriate time?  

The answer is simple: The industry has to change. Actioning change, on the other hand, will not be so easy. Ultimately, we need to expand the capacity of our clinicians by leveraging technology and dynamic clinical decision support, direct care to the appropriate level so that clinicians are functioning at the top of their license, drive intervention at the right time – not at the last minute – and engage patients where they live to proactively and effectively manage their health care needs.

Gaining insight into the complete patient risk portrait 

Actioning this change will require insight into the complete patient risk portrait – not just the risks that exist in the current care setting. We have a view of some of the patient risk in the acute setting, but it is a controlled environment. There are not medication adherence problems or the risk of failure to seek care, and there are no transportation concerns or food insecurities. 
We have a broader view of patient risk – such as ADL and Instrumental ADL (IADL) limitations and fall risk – in the post-acute facilities. We also get additional risk information if the patient is prescribed homecare. But these are episodic care settings, where care is provided for a specified time. The problem is that chronic disease is not episodic. It doesn’t last for just 30 days or 90 days. It is for life. 

We must use technology to connect the dots and create a complete portrait of risk that not only includes the risks we know about in the controlled environment, but also those risks in the uncontrolled environment – the community.   

Once patients are out of the controlled clinical environments and back in the community, we have dark knowledge gaps between provider touches. We know very little about what is happening at home or, as I call it, in the wild. We don’t know if they’re taking their medications as prescribed, if they’re engaged in managing their own health care, if they’ve got 23 cats or if they’re becoming increasingly more anxious. And we may not know any of these things until they end up in the emergency department. 

This is why we need a complete portrait of risk for each patient across the continuum. In all settings of care, we should all see the same portrait, which includes:

  • Clinical risk factors, such as opioid risk, use of medicinal sleep aides and a recent acute event
  • Social determinants of health, such as transportation, food insecurities or social isolation
  • Clinical profiles, such as depression, anxiety, chronic pain, engagement or ADL/IADL limitations
  • Live biometrics, including activity via bring-your-own device
  • Trended symptomatology that is consumer/patient generated
  • Clinical assist such as walkers, wheelchairs and oxygen therapy

A complete portrait of risk can shine a light into the dark gaps between care encounters. It helps facilitate smarter transitions of care, more appropriate utilization of post-acute services and safer transitions to home. This portrait can also reduce noise alerts to clinicians by creating clinical context around discrete data elements. 

One of the greatest benefits of a comprehensive risk portrait stems from the ability to use machine learning to provide insight into the synergistic relationships between individualized risk factors. For example, a patient with anxiety and dyspnea is at much higher risk of an emergency department visit than a patient with just one or the other. There is additional risk for a patient who requires a special diet and also lives in an area with food insecurity, or a patient with ADL/IADL limitations and a caregiver who also has physical limitations. The ability to see beyond the four walls of a clinical facility and into the community creates the full-color, contextualized risk portrait.  

Using technology to gain dynamic insight into the wild

In the health care industry, we have long focused on the sites of clinical care such as the hospital and emergency department, the rehab facility, the long-term care facility or the clinic. Now, we must focus more of our efforts into the wild: for the 70 percent of hospital discharges who go home with no specific post-acute care. 

Research shows that more than 62 percent of readmissions come straight from the community – not the post-acute venues – and 36 percent of readmissions occur in the first seven days. These are dramatic statistics that should make us stop and think about where we put our efforts. Our vision must be on how to gain contextualized insight from the community in a dynamic manner. We can no longer collect discrete data from disparate sources and expect to make a meaningful, timely impact. Individual vital signs without clinical context, such as risk profiles or symptomatology, often create noise alerts. Risk profiles viewed independently lack the compound effect of clinical risk and social risk together in aggregate. And lack of patient engagement creates a compounding risk factor that may be the greatest of all.

Technology is the tool that will allow us to aggregate multiple layers of discrete data from disparate sources across the continuum, apply clinical intelligence and insight and generate timely clinical decision support. Technology will provide mechanisms to seamlessly embed patient engagement into their daily life. Clinical intelligence models will provide insight into:

  • Contextualized biometrics and symptom trends
  • Prediction of fall risk rather than reaction to a fall
  • Notification of rising risk before an unscheduled clinical encounter occurs
  • Timing of care – now, tomorrow, next week
  • Modality of care – education, nurse in the home, in the physician’s office, video visit, phone follow up or e-assessment
  • Type of care – physician, nurse, physical therapist, social worker, aide, social service

With technology, we will span our clinical reach to the community – not on a scheduled follow-up time, but in a dynamic, right-time model. We will manage chronically ill patients where they are – at home – providing more touch, improved engagement, higher quality of life, better outcomes and lower cost. We will use technology to turn the light on in the wild.  

We share a commitment with long-term and post-acute care (LTPAC) providers to help make senior care management better than it is today. Learn more here.   

Are you attending the 2018 Cerner Health Conference? Come experience the innovative new solution Cerner is developing that will aggregate patient risk across the continuum and provide seamlessly embedded patient engagement tools. Register for CHC18.