Managing Patients with Chronic Conditions


How CAPE and a take on Apple’s Genius Bar are improving engagement and outcomes

Chronic diseases are the leading causes of death and disability in the U.S. According to CDC data, 6 in 10 American adults have a chronic disease, and 4 in 10 have two or more. Chronic diseases—which include heart disease, cancer, diabetes, COPD, and Alzheimer’s, as well as non-life threatening conditions such as dry eye, glaucoma, and tinnitus—are also the leading drivers of the nation’s $3.5 trillion in annual health care costs.

Medical Economics named treating patients with chronic conditions one of the top challenges facing doctors in 2020. It’s a complex problem because so much of the burden of managing chronic disease falls on the patient, and is incumbent on their self-care between appointments. And while patient education has been shown to play a key role in chronic disease management, time-crunched doctors can struggle to implement effective methods. Here’s how a specific patient engagement technique and technology can help. 

Empowering your patients via the CAPE technique

Research has shown that getting patients engaged in their own care improves outcomes and reduces unnecessary medical costs. So what can doctors do to better engage patients and encourage them to take control of their health? Motivational interviewing is one technique. 

The CAPE technique helps doctors engage and empower patients with chronic conditions by encouraging them to make changes for themselves.

Internist Damara Gutnick, M.D., used the acronym CAPE to explain the basics of motivational interviewing to Medical Economics:

Compassion. You’re doing everything in the best interest of the patient.

Acceptance and respecting autonomy. Patients have the right to change or not change. If they’re resistant, you need to respect that and not push them. 

Partnership. You and your patient are equals. You’re helping your patient move toward change, not telling them what to do. Using language like “Let’s discuss living with…” conveys empathy and collaboration. 

Evocation. This means pulling ideas for change from the patient. “As a doctor, I know a lot of reasons why you should quit smoking, but only you know what’s most important to you,” Dr. Gutnick said.

“When you use CAPE with your patients, you’re empowering them to make changes for themselves.”

The measurable effects of patient education

Research shows that patient education plays a pivotal role in chronic disease management. A 2018 study published in the Journal of the American Osteopathic Association found that 45 minutes of patient education improved management and outcomes for patients with chronic diseases.

A recent study found that patient education sessions measurably improved chronic disease patients’ attitudes and abilities in self-managing their care.

In the study, patients had a 45-minute visit with a second-year medical student after seeing their physician. “That one-on-one session measurably improved patients’ attitudes and abilities in self-managing their care,” reported Modern Healthcare

“Patients reported a greater understanding of their chronic disease and feeling better equipped to manage their health,” said lead author of this study, Alexis Stoner, Ph.D. “This is encouraging because these diseases typically require patients to take on a lot of responsibility in their care, often through changes in lifestyle.”

The study authors acknowledge that most practices don’t have the staff or time to devote to 45 minutes of patient education. That’s where technology comes in. 

New technologies address barriers to chronic disease management

Leveraging patient education technology is one way to achieve the seemingly competing goals of making chronic disease management easier for patients while not adding to doctors’ busy schedules. It also lowers health care costs and improves patient outcomes.

“As we’re working towards reducing the cost and burden of chronic disease, it’s imperative that we continue to innovate and take advantage of new and emergent technologies,” said Karen Hacker, M.D., MPH, director of the CDC’s National Center for Chronic Disease Prevention and Health Promotion.

Patient education technology can help achieve the challenging goal of easing the burden of chronic disease management for both patients and doctors alike.

HealthLeaders magazine describes several exciting new initiatives that are addressing chronic disease management with technology. New Orleans–based Ochsner Health System is pioneering a ground-breaking concept—a hybrid physical and digital patient experience—where patients select their own remote monitoring devices and apps from an “O Bar”—a retail location modeled after the Apple Genius Bar. A diabetes patient, for example, can stop by to check out a variety of blood glucose monitors and scales, as well as apps that could help address dietary, weight, or exercise issues.  

Another way to leverage technology is to incorporate patient education videos into your practice’s workflow. Videos that explain and illustrate common chronic conditions, such as diabetic retinopathy, can take the burden off busy doctors and educate patients at home or while they wait for their appointment. It’s an easy and impactful step to help manage patients with chronic diseases and improve adherence.

How digital patient education tools improve engagement

Colorado-based healthcare system Centura Health measurably improved care outcomes by employing patient education technology in their chronic disease management strategy, reported PatientEngagementHIT. Utilizing a tool that used EHR data to identify at-risk patients managing chronic diseases, Centura providers sent targeted educational modules to those patients between office visits to address the importance of health management and preventive care. For example, doctors sent mass emails to all of their diabetes patients with interactive modules including videos and Q&As to educate them in proper self-care strategies. 

Rendia offers this feature as well by allowing providers to send educational videos via email or patient portal to help improve treatment adherence. Customers have a dedicated account manager who can help set up email templates or links for a patient portal.

Sending patients educational videos via email allows you to reach them at home or work and encourage preventive care between visits.

The results are measurable. “We see an improvement in outcomes when patients are actually engaged in their chronic diseases,” said Matthew Vitaska, administrator of outcomes effectiveness and patient experience at Centura. Using his diabetic patient population as an example, he said, “From a clinical perspective, it means that they’re less likely to have sores or retinopathy, and more likely to have better vision. Overall, patients feel better if they’re not hyperglycemic.”

Centura has seen patients improve and maintain their blood pressure within just six months of using the program, a 22 percent improvement over patients who did not engage in the tool.

Rendia has many similar success stories from doctors using our technology to educate and engage patients on dry eye, glaucoma, and diabetic retinopathy.

Addressing varying levels of health literacy is critical to improving patient adherence and outcomes. To learn how to meet the needs of patients of all health literacy levels, read our whitepaper, Understanding Health Literacy.

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