Harm Prevention

Chronic Condition Management
 with Prescriptive Analytics

According to the National Council on Aging...

  • 92% of older adults have one, and 77% have at least two chronic conditions
  • Heart disease, cancer, stroke, and diabetes cause almost 60% of all deaths each year
  • Diabetes impacts 23% of the older population
  • An additional 57 million Americans aged 20+ have pre-diabetes
  • 90% of Americans aged 55+ are at risk for high blood pressure

Chronic conditions comprise more than three-quarters of the healthcare spend in the United States.

In addition to patient suffering, chronic diseases also contribute to higher rates of avoidable admissions and readmissions. The Center for Managing Chronic Disease has outlined the circles of influence that help manage chronic diseases and avoid complications.

These circles of influence include:

  • Self-management
  • Family
  • Clinical expertise
  • Work/school
  • Community awareness
  • Environment
  • Policy

Chronic diseases are complex problems that lead to higher mortality, utilization of services, and a greater cost. A recent study released by the Centers for Disease Control and Prevention (CDC) concluded that nearly 66% of all adult discharges from community-based hospitals have Multiple Chronic Conditions (MCCs). MCCs are associated with higher numbers of avoidable admissions and hospitalizations, and increase the risk of readmissions. Moreover, rates of avoidable admissions, hospitalizations, and readmissions are compounded by payer type, race, sex, and age indicating the complex nature of MCCs and the interplay with racial and socioeconomic factors.
As our population ages and chronic conditions are compounded, managing individuals with one or multiple illnesses will take an even more central role. Finding ways to predict possible readmission risks and complications to drive interventions and self-management will help improve overall health while reducing the risk of hospitalization.
The good news is that evidence strongly suggests that tailored interventions are not only feasible, they are highly effective at reducing admissions, length of stay, and avoidable readmissions for these individuals.
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