The COVID-19 pandemic shed light on how the U.S. healthcare system is not effectively structured to address the needs of people with chronic illnesses like diabetes, cardiovascular disease, or chronic obstructive pulmonary disorder (COPD)—and we have some of the highest rates among OECD countries. Most healthcare entities were not prepared to respond to the shift from in-person to virtual care resulting in many individuals living with chronic illness forgoing essential routine treatments. 


Virtual care is proving its value as a necessary component of chronic care management (something that has been evident to us for a decade at Cecelia Health) – and this is perhaps one of the most important silver linings to emerge from the pandemic. It’s evident that virtual care for higher-risk populations can reinforce treatment plans, reduce patient confusion, and influence positive behavior change to improve health and reduce spend.  


Evidence from recent research offers important lessons to make chronic care programs more effective in the future: 


1) Proactive engagement is essential for effective chronic care. A March 2021 study published in the Annals of Family Medicine examined factors associated with top performance in primary care for diabetes. The researchers compared the strategies, facilitators, and barriers identified by 31 clinical leaders in primary care clinics across Minnesota. They found that top-performing clinics differentiated themselves primarily by emphasizing data-driven, proactive outreach that incorporated virtual care to intensify treatment. This suggests a proactive, continuous care approach provides the essential continuum of care for successful chronic disease management.  


2) Collaboration is critical in the prevention and management of illness.  While effective treatment and medication adherence are certainly important to improving outcomes, clinicians can make a big impact when they understand and respond to the unique fears, challenges, and barriers that individuals may face. And this is much easier done via a coordinated team effort that makes use of shared patient data to strengthen care plans rather than via independent review. Through virtual platforms, clinicians can more easily develop systems of team care that provide support for patients that responds to their individual needs. A virtual, team based approach can also enable longitudinal follow-up and monitoring otherwise impossible during a few 15-minute appointments throughout the year with a primary care provider.1 Integrated, virtual care teams can also offer breadth of experience in addressing disparities and closing health equity gaps. 


3) Combine a human element with the convenience of technology for better outcomes. While some people living with chronic illness may have access to the latest and greatest technology and prefer a highly digital modality of engagement, the majority, and in particular older populations, don’t utilize health apps.  Additionally, research suggests that empathetic clinicians empowered by data are more effective at improving patient clinical outcomes with the right clinical conversations to uncover SDOH barriers, address personal care needs, and motivate behavior change. Chronic care programs that deliver on the metrics that matter (high engagement and satisfaction, increased adherence, improved quality measures, better health outcomes, etc.) foster human relationships that are necessary to build trust with an appropriate mix of in-person and telehealth visits, as well as remote monitoring, to meet the diverse needs of people with chronic illness. 


4) Personalization is no longer nice-to-have; it is a necessity. People are more engaged with their healthcare than ever before, and healthcare consumers are expecting seamless experiences enjoyed via other everyday digital platforms such as Amazon, Netflix, and Uber. Many technologies, like AI and chatbots, have been introduced through digital health apps to meet this need. However, recent research from the Harvard Business Review suggests that patients have a resistance to AI based on a belief that it doesn’t take into account their unique characteristics and circumstances. To deliver truly personalized experiences, human connection is still necessary to build trust, uncover specific needs and address them—especially among highly complex populations who have chronic conditions, associated comorbidities, potential mental health concerns, and other factors that affect overall health.  


5) Utilize evidence-based programs to support chronic disease management. When evaluating integration of a third-party partner to support broader chronic disease management efforts, it’s critical to evaluate whether that partner adheres to or incorporates evidenced-based standards. For example, the American Diabetes Association (ADA) and the Association of Diabetes Care and Education Specialists (ADCES) offer resources for providers and supporting clinicians to consider when structuring effective diabetes care. Moreover, organizations can obtain accreditation from organizations like NCQA and ADCES to certify that their chronic care approach meets relevant criteria. With the proliferation of new technologies and approaches, evidence is paramount and many solutions simply lack the rigorous evidence to justify their claims.  


The current state of chronic disease prevention and management in the U.S. demands action to adequately care for people navigating a complex care journey. Organizations that apply these core tenets to their chronic care management efforts will be better prepared to provide effective longitudinal and continuous treatment necessary for chronic care management, instead of greater reimbursement for episodic treatment that continues to drive higher costs for plans, patients, and the overall healthcare system.