Effectiveness of chronic care management in diabetes

By integrating chronic care via telemonitoring, wearables, home-health clinical devices, patients can reduce the healthcare cost, says Abhay Chopda

Chronic care management, Diabetes, Abhay Chopda, Pervasive metabolic disorders, WHO, Blood pressure, Optimal care delivery system, IoT devices, Algorithm-Driven Care, Healthcare technology, Remote patient monitoring, Continuous care, Chronic care model, CliniVantage Healthcare Technologies

Diabetes is one of the most pervasive metabolic disorders in the world; according to the WHO, 422 million people suffer from diabetes worldwide with a prevalence rate of 8.8% in adults. Type 2 diabetes is becoming increasingly common in adults and children, fueled largely by the obesity epidemic. It has been observed that between 33% and 49% of patients do not meet targets for glycemic, blood pressure, or cholesterol control highlighting resulting in the need for high-quality diabetes care.

In a country like India, a lot of times patients ignore the signs of being prediabetic, which later on progress to type 2 diabetes. Hence, the treatment for this chronic disease requires constant blood glucose control, which signifies the importance of monitoring vitals, blood pressure levels, foot care and insulin intake at regular intervals.

To address the challenges like fragmented care setting, lack of clinical information capabilities, duplicates services caused due to inexistence of an optimal care delivery system, chronic care management has shown to be an effective framework for improving the quality of diabetes care. Automated remote health monitoring and assessment makes it possible for improving the quality of healthcare. By combining innovative technology with medical IoT devices and an optimal care delivery system we can eliminate the need for patients to physically visit the clinicians office. It enables interaction with care providers with real time health care records for better care management.

Computerised Algorithm-Driven Care

An efficient care model should support all the core components of a chronic care model that is an efficient delivery system, self-management support, clinical information system, decision support, reliance on community resources and health system to enhance patients’ awareness and enhance their engagement and experience. Now, for patients to seamlessly transition between different facets of chronic care management, efficient care delivery systems or an intuitive healthcare platform is required to improve coordination between providers and patients.

The healthcare technology solution offers a platform for prediabetes or diabetes to receive 24*7 support to prevent the occurrence of any critical medical event. Such robust solutions have integrated template engine that allows easy configuration to meet the requirements of any doctor or hospital. It provides real-time access to patient's information through a template-driven method for capturing patient's vitals, habits, history, complaints, medication, services and other details that are important to evaluate treatment plans for the patient.

The provider is updated with every development of patients health through notification or alerts. These alerts show data points related to the vitals of the patient which he considers critical to his treatment plan and would require his attention. This type of monitoring can help with early intervention when specific symptoms are detected. It also allows the patient to be actively involved and engaged in the monitoring process of his/her diabetes. It empowers the provider with greater mobility and flexibility to monitor his patients from any location and at any point in time; allowing him to alter a patient's treatment plan on an on-going basis. With the use of technology, the doctor can order for regular tests which he deems important for the diabetes patient to regularly check on the condition of the patient's eyes, heart, kidney, liver, etc. It will also help him make in-person consultation more effective as now all the data is available to him on the platform which he can easily refer to rather than just relying on the patient for the details.

Remote patient monitoring

To alleviate the burden for patients with chronic diseases, remote patient monitoring makes it easier for care teams to track, manage and engage with patients who need extensive and continuous care. This evidence-based approach can transform primary care across different practice settings to improve outcomes. Such programs facilitates and produces effective interactions between care team and patients for effective assessment of the patient’s health on the real time basis. In addition to this, we have several health related apps, wearables and in-home devices which are focused on general health, exercise, wellness and diet. These instruments empowers patients and providers to record the vitals on a regular basis to generate insights for timely advice. The amalgamation of such technology with an efficient chronic care model makes the wheel rolling for remote care. Innovative technology affords a low-cost, flexible means to supplement health care and reshape chronic care. This kind of interventions can be a powerful way to improve provider practice and help patients live more successfully with chronic disease like diabetes.

Cost-effective treatment

By integrating chronic care via telemonitoring, wearables, home-health clinical devices, patients can reduce the healthcare cost. As there is a shift toward home health, providers have an opportunity to integrate digital health tools into treatment plans and remote monitoring to help manage patients with chronic conditions, provide proactive care, and lower costs. With telemedicine, patients can quickly consult with their care provider about the new symptom as it appears in real-time and in return receive recommendation to change the treatment. This ensures that the patient receives the care they need on a timely basis and reduce the chances of a lapse in treatment and hospital readmission. This reduces the cost of care for both patients and care providers.

Improved patient experience

With an optimal chronic care model, patients do not need to take time off from work, find transportation to the clinic, spend money for parking or any of the other burdens associated with attending a doctor's appointment. The integration of mobile health application with in-home medical devices can act as a catalyst for effective management of chronic diseases to enhance the patient experience and outcome. The patient engagement tool enables the patient to upload all their medical records and episodes. He can view his treatment plan to understand his medication, insulin schedule, or any tests that he needs to take along with his exercise regime and diet plan. He can capture any other symptoms or any episodes that he may experience in between his personal consultation with the doctor. The patient engagement tool can also facilitate interaction with similar patients to educate each other with different care plans and precautions to reduce the adverse effect of diabetes.

Public health implications

Innovative integration of IoT devices like health kiosks and health ATM in the community can provide very valuable early insights in disease prevalence and incidence. Ageing, population growth, a rising burden of chronic and non-communicable diseases along with technological advances on the other side are driving the transformation in the primary care. Hence, with a unique AI integrate platform the Government can generate insights to make multi-sectoral policies and actions that are required to combat the adverse spread of the chronic illness. The technology accumulates health data nationwide and empowers the Government to provide person-centered care and encourage positive and healthy lifestyles in individuals and communities

Prevention and early intervention associated with the integration of management through technology can be a multi-dimensional and systemic solution to address the complex problem of how to provide care for chronic diabetic disease. With the broader availability of remote glucose monitoring, telemedicine, and other technological tools, a care coordinator can facilitate goal-oriented care for effective management of diabetes.

Abhay Chopda is co-founder with CliniVantage Healthcare Technologies Inc.