As healthcare organizations scramble to figure out how to care for patients during a public health emergency, it’s easy to let chronic care management services fall behind. In fact, an Epic study revealed that preventative cancer screenings dropped between 86 and 94 percent after the U.S. declared a national health emergency. While cancer screenings are rising again, weekly volumes are still far lower than before COVID-19. This has serious implications, as cancer treatment is most effective when detected early. Delayed screenings could lead to cancer diagnoses after they’ve progressed to a later stage that is harder to treat.

The drop is likely due to concern about the safety of in-person care amidst the COVID-19 era. As a result, many practices are transitioning from in-person ambulatory care to technology-enabled virtual care paradigms, which means we have to think creatively about how to conduct chronic care management in the COVID-19 era.

Read on to learn three ways technology can help you keep your patients healthy using chronic care management in the rapidly changing healthcare environment.


1. Identify your high-risk patients with risk-stratification software.

If you want to deliver effective chronic care management services, prioritizing patients with the highest risk is a good place to start. Often, these patients include those with chronic disease, those at risk of chronic disease, and those who are overdue for preventative care.

Learn more about targeting patients for population health outreach.

Many patients are missing necessary chronic care out of fear that they may be exposed to coronavirus if they seek in-person care at the doctor’s office. As the Epic study revealed, this includes preventative cancer screenings, such as colon, breast, and cervical cancer screenings. Other groups of your population may include those who are more likely to develop the chronic disease—or even multiple chronic conditions—based on various data.

For example, patients negatively impacted by Social Determinants of Health (SDoH) may experience additional barriers to chronic care management, especially as people are losing their jobs due to COVID-19-related closures. And, with the increased stress and uncertainty surrounding coronavirus, it’s not surprising that many people are relying on unhealthy behaviors to cope, thereby worsening their existing conditions. Preliminary studies in China are already suggesting that anxiety, depression, and self-reported stress are “common psychological reactions to the COVID-19 pandemic”.

It would be incredibly time-consuming, if not nearly impossible, for your care team to manually comb through the EHR looking for patients who match certain criteria. In fact, doing so can even result in overgeneralizing patient groups, which means chronic care management outreach could be less relevant and personalized for some individuals included in the groups.

A more effective and scalable way to identify your high-risk patients is to use a technology platform that leverages your EHR data and identifies individuals who meet specific criteria. Sophisticated technology can enable better chronic care management by automatically sifting through your EHR data that already exists, from age and demographics to more nuanced details, like hereditary diseases, preexisting chronic conditions, and utilization history.

Learn more about using data to refine your patient outreach strategy.

Once you’ve used technology to sort through your health data, you or a chronic care manager can leverage communication tools, such as HIPAA-compliant texting, to establish automated workflows that send customized messages prompting your patients to take action. This ensures the right patients receive the right notifications and resources to empower them to improve their own chronic care management. And, because it’s automated, your care team can scale the number of patients they can reach without overextending your clinicians and staff.


2. Equip patients to self-manage their care at home.

One of the ways you can remotely engage patients is by offering resources and technology that empowers them to manage their health care from home. From remote monitoring technology that syncs with an EHR, such as blue-tooth enabled blood pressure cuffs, to home screening kits for diseases that can be tested remotely, there’s a variety of ways you can stay on top of chronic care and patient health during coronavirus.

For example, one of our clients conducted outreach via secure text messaging, offering a unique care option for patients eligible for colon cancer screenings. Vice President of Clinical Innovation Lisa Blue says, “Our secure texting platform enabled them to offer patients who had an office visit within the last 12 months a home screening kit or mammography requisition sent directly to their home rather than obtaining it in the office. In just one week, they received responses from over 450 patients for colorectal cancer screening alone!”

By giving patients easy-to-use tools and instructions for chronic care management at home, you can minimize in-person office visits while promoting virtual patient engagement with their health care.


3. Triage patients to the right kind of care.

From primary care telehealth appointments to virtual waiting rooms for in-person care, there are lots of ways you can leverage technology to triage patients to the point of care that will both meet their chronic care needs and minimize their exposure to COVID-19. By offering multiple options for care delivery, patients with chronic conditions or other health concerns can receive the care they need, in the safest way possible. Care options may include:

  • A nurse triage line for urgent care
  • A COVID-19 screening chatbot that uses artificial intelligence to triage patients
  • Remote video appointments for check-ins or replacements to scheduled in-person visits
  • In-person care for emergencies
  • HIPAA-compliant texting for ongoing patient/provider communication and keeping patients up-to-date with your office’s safety precautions

… and more.

You don’t have to let coronavirus delay necessary chronic care for patients and others who need help with chronic care management services. Together, we can reimagine digital care delivery in the evolving healthcare landscape and deliver better chronic care management.

Contact us today to see how.