Richard Royer
Chronic illnesses and related conditions affect every age group, but they are significantly more prevalent in older adults. According to data shared by the Centers for Disease Control and Prevention, one in four American adults that are under the age of 65 have multiple chronic conditions. That number jumps to three in four adults in the 65 or older category.
As the number of older adults in this country grows, the total number of chronic conditions also increases. Because of these alarming numbers, there is a greater need than ever for chronic disease management and preventive care services in the long term care setting.
Chronic diseases are the leading cause of death and disability in the United States. For patients of any age, the effects of chronic illnesses can be devastating. In older adults, chronic diseases can lead to things like repeat hospitalizations, nursing center admissions, the loss of independence, or a reduced quality of life.
Estimates vary, but most suggest that between 80 to 90 percent of people over the age of 65 have at least one chronic disease. Few institutions are exempt from dealing with patients suffering from chronic ailments like arthritis, cancer, diabetes, heart disease, high blood pressure, stroke, and other conditions. What is also becoming clear is that health care providers need to change the way they traditionally have handled these cases in order to provide the quality of care patients deserve, and to keep up with changes in health care payment models.

Take A Proactive Approach

Close to 90 percent of national health care costs are related to chronic conditions. Lowering those costs, while improving quality of care, is a big focus for both government programs and commercial insurers that are driving accountable care initiatives and offering value-based reimbursement as incentives.

Moving forward, it will be difficult for medical professionals and facilities to thrive unless they put a bigger emphasis on helping patients with chronic conditions and better managing them so they’re less likely to experience serious complications, like landing in the hospital—again, and again, and again. Health care providers that care for older adults need to move away from an episodic care approach to a more holistic model.

This type of shift will require changes to health care business cultures, workflows, staffing, technology, and data usage. To drive change and push the line on chronic disease management and prevention for older populations, providers will need to take some positive steps.

1. Completely Coordinate Care

Patients with chronic conditions must rely on an entire team of caregivers. Specialists, pharmacists, geriatrics nurses, and many other providers might be tasked with helping one individual patient manage multiple chronic conditions. A patient’s care plan needs to be coordinated across all of these different providers and areas of care.

Coordination is especially important during care transitions. If patients are released from a hospital and moved to a long term care facility, they should receive seamless care. However, in these scenarios, communication breakdowns often create gaps in care that lead to patients being readmitted to the hospital.
When a stroke patient leaves the hospital and transitions to a post-acute care, assisted living, or nursing care facility, the hospital must work cooperatively with the facility to guarantee that the patient receives the appropriate ongoing follow-up care. Better partnerships create better outcomes for patients and reduce hospital readmissions.

Because so many chronic disease patients require medication, another way providers can improve care coordination is by connecting with the pharmacist community. At the most basic level, that could be automatically getting a patient’s prescription renewed for them, and letting the patient know it was handled. This is a good step. Even better, there are some emerging efforts to develop triggers that would alert doctors when patients stop picking up prescriptions. Right now, that connection generally doesn’t exist, but progress here could help strengthen the link between pharmacists and providers.

One can’t underestimate the importance of this because medication control—or the lack of it—is a major factor in everything that’s going right and wrong when it comes to managing chronic diseases and helping keep patients living with them at optimal health levels.

2. Maximize Use Of Patient Data

Coordinating care is easier when patient data is shared among all members of a patient’s health care team. Electronic health record adoption and use is necessary across all institutions and physician clinics that care for patients. Multi-way data exchange is essential to understanding the complex needs of a patient with multiple chronic conditions. Truly coordinating care across physician practices, hospitals, and long term and post-acute care providers can only happen when each group has access to patient information and can share data with other providers.

A senior patient who enters a long term care facility with heart disease, a history of a stroke, and arthritis needs to receive care that addresses all of these conditions. Information from previous and current providers is the key that helps the long term care provider understand what must be done to manage the patient’s various conditions.

The point is, providers across the care continuum must adopt medical record technology. Even those that are not eligible for financial incentives for adopting meaningful use must put the technology in place so they can maximize the use of patient data that is critical for chronic disease management and reducing care costs.

3. Progress To Performance Improvement

Long term care facilities are currently required to have quality assurance programs in place. To add to that, new regulations will go into effect next year that will require a formalized approach to performance improvement be part of every facility’s ongoing systems. Starting now, providers need to implement more proactive evaluation and improvement processes. This will allow facilities to not only meet the new mandates, but also progress from a reactive state to a proactive one where they are able to prevent issues and drive better patient outcomes.

Moving Beyond Compliance

Quality assessment and assurance at most nursing care centers and long term care facilities often works in retrospect and is done to adhere to regulations. But providers can do more with the resources they have. Organizations can shift the focus away from compliance and onto performance improvement.

One way providers can make this happen is to share the responsibility of continuous improvement with staff members, patients, and families. Providers can ask for feedback, give patients opportunities to make choices about their own care, and apply evidence-based practices. By taking these steps and not settling on quality minimums, providers can give patients better care experiences.

The oldest of the baby boomers turned 65 a few years ago, and the country is going to continue to see a rise in this age group over the next few decades. To address the chronic care needs of the growing number of older patients, health care providers need to take steps now to coordinate care plans, improve communication across care teams, and proactively engage patients.

Richard A. Royer, MBA, is chief executive officer of Primaris. Royer can be reached at or (573) 817-8300.