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When it comes to managing chronic conditions, patients need more than just a treatment plan. They need a partner who will meet them where they are, engage them in care, and provide them with information at a pace they can handle. By considering a patient's unique needs and preferences, physicians can build trust while empowering the patient to take ownership of their health. This patient-friendly approach to chronic condition management is more likely to yield positive and consistent health outcomes. Without it, even the most carefully developed care plans may fall short.
To make providing this level of support feasible across a busy practice, care teams need to focus their efforts—starting with the patients who need the help the most. By analyzing data and regularly reviewing reports, care team members can identify which patients with chronic conditions haven’t seen a physician recently. Instead of waiting for patients to come into the office, care team members can preemptively connect with patients who are at risk for an acute episode, such as an unplanned hospital visit. During these conversations, a care team member can find out how patients are doing, why they haven’t seen their physician recently, and what might be preventing them from coming in for an appointment.
These conversations can be as unique as the patients themselves. Some people are not ready to talk about their condition or how to manage it. Others are ready to schedule appointments but don’t have reliable transportation. Some don’t realize they even need to see the physician and could use education about how to keep their condition under control. Asking the right questions, and truly listening to the patients’ responses, is essential during these exchanges to understand what’s preventing a patient from getting the necessary care they need and want.
This patient-friendly approach had a big impact when a member of the CareAllies team who works with Valley Organized Physicians, an independent physician association we support, called a patient who had uncontrolled diabetes. During the first conversation, the patient made it clear he was not interested in discussing his condition. Instead of pushing the patient, she focused on more general topics – allowing him to open up about his overall wellbeing in a manner where he felt most comfortable. Over the course of the call, it became clear there were several social determinants of health (SDOH) factors at play. For instance, he mentioned he had not left the house recently, was mostly sedentary and had little social interaction. Understanding the effect social isolation can have on patients, the care team member connected the patient with a nearby senior center that was walking distance from his home. Over the next few weeks, she checked in regularly to see how things were going and encouraged small lifestyle changes, based on the patient’s stated priorities. Soon, the patient was ready to talk about his diabetes and health goals, so he and the care team member set an appointment to check his A1C–a key diabetes management strategy. As the patient continued to invest in his health, he made bigger activity and diet changes, lost 40 pounds, and lowered his A1C.
Helping patients manage chronic conditions requires focused connection. When care teams use data to identify those who need support, take time to understand each patient’s situation, and engage with empathy, consistency and clinical best practice, patients are far more likely to remain involved in their care and make meaningful, lasting improvements in their health.