Developing a Market-Driven Chronic Care Strategy

Chronic diseases account for an outsized and growing portion of health care resource utilization and costs. Care for patients with chronic conditions, often provided by multiple disconnected clinicians, is frequently disjointed, duplicative or hit or miss.

As the evolution to value-based care accelerates, chronic care must become a strategic priority for all health systems. Even in a fee-for-service environment, a chronic care strategy can yield not only cost savings, but also the potential for increased ambulatory revenue as chronic patients are more systematically guided to evidence-based screenings, services and interventions within the System of CARE. It reflects the organization’s mission and commitment to its community and can be a part of enterprise channel strategy, creating new access points and fostering engagement and loyalty.

Sg2 recommends an analytic approach to understand and segment the chronic care population in your market and assess your capabilities in this arena.

Size and segment the market.
  • Size the chronic care market and understand its growth. An analysis of the total chronic care market size—current and future—is fundamental to enable realistic, quantitative decision making and strategic planning.
  • Strategically define the target population. Consider your current exposure to risk or plans for future risk-based ventures.
  • Identify quality and cost challenges to be addressed. Specifying the quality shortcomings that need to be improved and/or global aims relating to cost will help determine appropriate interventions.
  • Risk stratify based on clinical input and analytics. Both analytics and clinical input play an essential role in patient segmentation into meaningful subgroups for targeted treatments and service delivery.
Inventory and optimize organizational assets.
  • Gauge organizational structures and capabilities. Determine whether your organization has the management structure, clinical integration, access channels and population health competencies required to strategically and cost-effectively manage chronic care.
  • Consider alternative workforce models. These models emphasize increased attention to patients at highest risk and care delivery outside traditional settings. Consider dedicating comprehensive care physicians or extensivists to your highest-acuity patients, and/or using mobile teams to bring care to the patient’s home.
  • Deploy facilities in high-need locations. Evaluate the addition of bricks-and-mortar sites of care in areas of high demand, limited services or both to ensure your sickest patients have easy access to care. Use analytics such as Sg2’s State Data, Ambulatory Market Strategist and Physician Supply and Demand to plot care sites vs need.
Seek partners to bridge the gaps.
  • Find payers with shared goals. A broad spectrum of payers are looking to partner with health systems—at the top of this list are payers offering Medicare Advantage and self-insured employers. Alternately, in value-based or shared savings contracts, implementing cost-effective chronic care benefits the payer, the provider system and the patient, a triple win.
  • Join with community partners to solve tough problems. Since only 20% of a population’s health is attributed to clinical care and the remaining 80% can be attributed to environmental, social or behavioral issues, partnering with community organizations can help ensure your patients’ nonclinical determinants of health are addressed.
  • Integrate behavioral health resources into chronic care. Nearly one-third of patients with chronic medical conditions suffer from comorbid behavioral health disorders. Offering integrated, patient-centered care for these patients can boost outcomes and reduce costs.
  • Engage technology partners to achieve scale and accelerate care. Deploy technology to scale the clinical workforce, optimize care management and promote patient engagement. Assets such as virtual health, social media and care management tools should be factored into your chronic care strategy.
  • Create a management structure to support partnerships. The broad array of partnerships required for an effective chronic care strategy demands a collaborative approach to decision making. Consider steering committees with representatives from various partners and/or matrix management. Ensure that goals and incentives are aligned and communicated across partnerships.

Capture savings and revenue to sustain the strategy. For organizations in shared savings or total-cost-of-care contracts, it pays to drive down the expenses of high-cost chronic disease patients. In the fee-for-service world, better care for chronically ill patients will lower readmission penalties and demonstrate value to payers.

Contact Sg2 for help with developing an analytic approach to understanding and segmenting the chronic care population in your market, as well as assessing your health system’s capabilities in this arena.

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