Simplifying chronic disease management with CareCommunity
According to the Center for Disease Control (CDC), over 85% of health care spending is for people with one or more chronic conditions. Direct medical costs for diabetes alone are over $245 billion! Many of these costs are unnecessary and associated with poorly adopted and managed care plans. As our population ages, these costs are at risk of continuing to rise.
Nearly every Life Plan Community has as its mission, to provide a living experience supporting health, wellness and vitality. Even though chronic disease is an illness by definition, successfully managing these conditions with care plans, technology and a support system can contribute to the wellness and vitality of afflicted residents.
In recent years, a focus on primary care chronic-disease management models has emerged and has proven successful for a number of different conditions. The Patient Centered Medical Home (PCMH) is an approach that provides care-planning, training and a ‘patient coach’ support system to chronically ill residents. The primary goal of most care plans is to keep persons out of the Emergency Room due to adverse clinical events that are all too common among this community. There are many examples of success in literature from both CMS-sponsored experiments as well as traditional payer/provider models.
In my opinion, Life Plan Communities are in the ideal time and place to create these programs and sponsor such initiatives in their communities. An LPC has obvious advantages over traditional PCMH offerings, the most important being that their residents are essentially a captive audience. An LPC can provide the care plan, the technology, and the support system to make the model wildly successful and can see firsthand the results of the program by simply walking down the hall.
This ‘self-contained’ model becomes infinitely more powerful by centering it around a robust Personal Health Record (PHR). By offering its residents their own PHR, LPCs can connect them to their primary care physician, automate their care plans, monitor progress and gently intervene in a proactive manner if warning signs are witnessed. On the same technological platform, residents can log their exercise results through FitBit or upload their Silver Sneakers activity, and they can easily upload home test results using wireless scales, blood-pressure monitors and glucometers. This automated activity and data-sharing happens naturally and is easy and non-disruptive to even the most technology-wary senior. With their PHR connected to the pharmacy, a resident’s patient coach (or family member) can be alerted if they fail to fill or refill vital prescriptions. Helping residents manage their chronic disease in this manner will substantially reduce the number of Emergency Room visits, hospital admissions, and general negative outcomes from a poorly managed process, or no process at all.
With the introduction of MatrixCare’s CareCommunity next month, this vision for Life Plan Communities is becoming a reality. Soon, LPCs will be able to market their mission of health, wellness and vitality to an even greater number of future residents…those with chronic conditions.
Senior Vice President – Life Plan Community Division