Stop Chronic Condition Complications

One integrated delivery network effectively prevented diabetes related complications and deterioration for a group of high-risk patients

Lower cost and improve care for patients with chronic conditions

There are two trends that have the potential to completely change healthcare in the US:

  • The movement of more care activities into outpatient/ambulatory settings
  • The exponential rise of chronic conditions

Helping providers focus on rising-risk patients and reduce complications related to chronic diseases including asthma, diabetes and allergies

At the convergence of these two trends is a system tasked with controlling costs while improving health outcomes.

While chronic conditions account for more than 86% of all healthcare dollars, these are also some of the most preventable and effectively controlled illnesses. But current technology isn't equipped to provide the insights needed to stop complications and target care activities that will help better manage patients with chronic conditions and drive more effective clinical action.

Helping providers focus on rising-risk patients and reduce complications related to chronic diseases including asthma, diabetes and allergies

So we equipped Jvion's Cognitive Clinical Success Machine to help providers target rising-risk patients and reduce complications related to chronic diseases. It does this using more than a quadrillion clinical and non-clinical considerations and thousands of data elements. To this data, over 150 thousand self-learning Eigen Spheres are applied for each patient in real time to provide high definition views into patient health 30, 60, 90 and up to 365 days into the future.

These views help providers prevent:

  • Asthma complications
  • Diabetes complications with the likelihood of admission
  • Avoidable admissions for other chronic conditions including heart disease, obesity, and allergies
  • Rising-risk patients with the likelihood of becoming high-risk

As a result, providers have the actions and recommendations needed to:

  • Prevent diabetes related complications and deterioration
  • Avoid preventable admissions due to chronic disease-related complications
  • Lower the cost of care for patients with chronic conditions including asthma, diabetes, heart disease, obesity, and allergies
  • Prevent rising-risk patients from becoming high-risk

Chronic Conditions – Topic Deep Dive

According to the National Council on Aging:

  • 92% of older adults have one chronic condition, and 77% have at least two
  • 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

These conditions comprise more than three-quarters of the healthcare spend in the United States. In addition to patient suffering, chronic diseases also drive what could be avoidable admissions and hospitalizations along with higher rates of readmissions. The Center for Managing Chronic Disease has outlined the circles of influence that help manage chronic diseases and avoid complications. These spheres include:

  • Self management
  • Family
  • Clinical expertise
  • Work/school
  • Community awareness
  • Environment
  • Policy
Nearly 66% of all adult discharges from community-based hospitals have multiple chronic conditions.

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, 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.

References

National Council on Aging http://www.ncoa.org/press-room/fact-sheets/chronic-disease.html

The Center for Managing Chronic Disease: What is Chronic Disease https://cmcd.sph.umich.edu/about/about-chronic-disease/

Steiner CA, Friedman B. Hospital Utilization, Costs, and Mortality for Adults With Multiple Chronic Conditions, Nationwide Inpatient Sample, 2009. http://www.cdc.gov/pcd/issues/2013/12_0292.htm

We are Measured by Your Success

Hear What Our Customers Have to Say