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Why is Coordinated Care the Best Approach for Preventing and Managing Chronic Diseases?

The prevalence of chronic conditions such as heart disease, diabetes, cancer, depression, and others in the United States is striking. Sixty percent of Americans have one chronic condition, and 40% have two or more, according to the Centers for Disease Control and Prevention. High blood pressure affects nearly half of U.S. adults, but only about 1 in 4 of them have the condition under control, increasing the risk of heart attack and stroke for those who don’t.

Then there’s the financial toll of chronic disease, which affects us all. People with chronic conditions make up 90% of the $4.1 trillion in annual U.S. health care spending.1 Median health care costs for employers rose 8.2% from 2020 to 2021 alone, and the increase was driven primarily by heart disease, cancer, and musculoskeletal conditions.2 Higher employer health costs are often absorbed by employees in the form of higher monthly premiums and/or deductibles.

A better way to treat chronic disease

Part of the difficulty in treating chronic disease is the way traditional health care systems are organized. It can be confusing to patients, who often must manage their own care, to figure out what exams or screenings they need, when they need them, and where to get them. This makes prevention more difficult. It can also hinder early intervention when diseases are easier to treat. Early detection and intervention are critical factors in cancer survival rates, for instance.

At Kaiser Permanente, a nonprofit health plan and one of the largest multispecialty medical groups in Colorado, our electronic health record (EHR) is a key tool in preventing and managing chronic disease. All doctors in our medical offices have instant, real-time access to members’ health records. The doctors use the system to coordinate care across medical specialties and locations, which is important because multiple doctors are often involved in managing members who have chronic diseases.

What coordinated care looks like

Here’s an example of what that care coordination might look like. A Kaiser Permanente member with diabetes and high cholesterol sees their primary care provider for a wrist injury. The clinical staff person rooming the member offers to provide any needed immunizations and reminds the member to stop by the in-office lab if they are due for blood work to monitor their diabetes and cholesterol. Monitoring chronic conditions is simply a part of routine care at any visit to a Kaiser Permanente medical office, thanks to timely reminders in the EHR.

Next, the primary care doctor evaluates the member’s wrist and orders X-rays — again, something that can be completed without leaving the building at nearly all Kaiser Permanente medical offices. After getting the images back, the doctor sends a message to an orthopedic specialist through the EHR describing the nature of the injury. The orthopedic specialist views X-ray in the EHR and promptly advises the primary care doctor on the next steps for the member. All of this occurs during a single appointment for the member.

The EHR also triggers automatic reminders for routine checkups and screenings for high blood pressure, diabetes, various types of cancer, and more. If a problem is discovered, members are enrolled in our unique Population Care Management program, which pairs them with a registered nurse who helps coordinate their care and provides education on how to delay the progression of their condition so that they can achieve their best possible health.

Cardiologists at Kaiser Permanente in Colorado developed another unique program, the Integrated Care for Improved Heart Function Program, pairing members with heart failure with a team that creates personalized treatment plans, coordinates referrals, and monitors members regularly. Programs like this help patients like Van Card develop heart-healthy habits and reduce the risk of a cardiac event, such as a heart attack or stroke.

A system that generates results

This 360-degree, coordinated approach to chronic disease at Kaiser Permanente enables doctors to:

It also empowers members to understand and manage their chronic conditions through patient monitoring. It’s a system that can help lead to better outcomes. For instance, in 2022, Kaiser Permanente was the highest-rated health plan in Colorado for 43 of approximately 130 effectiveness of care measures, including controlling high blood pressure, statin therapy for patients with heart disease, comprehensive diabetes care, and 15 mental health measures.3

Part of what can make chronic diseases so difficult to prevent or treat is the fragmented nature of conventional health care systems. It can be an especially difficult system for patients with chronic conditions to navigate because their care needs are more complicated. Coordination relieves them of this burden, replacing it with instead with efficient, effective care that can help keep them at their healthiest.

Tracy Lippard, MD is board-certified in internal medicine and geriatric medicine, and joined Kaiser Permanente in 2006. She is the Executive Director of Complex Needs, focusing on chronic conditions management. She was named a Top Doctor by 5280 Magazine in 2019. In her free time, she enjoys traveling, gardening, cooking, and loves spending time with her family.

1 National Health Expenditure Data: Historical. Center for Medicare & Medicaid Services. December 15, 2021.
2 Business Group on Health. 2023 Large Employers’ Health Care Strategy and Plan Design Survey. August 2022. Available at: resources/2023-large-employers-health-care-strategy-survey-intro
3 The source for data contained in this publication is Quality Compass® 2022 and is used with the permission of the National Committee for Quality Assurance (NCQA). Quality Compass 2022 includes certain CAHPS data. Any data display, analysis, interpretation, or conclusion based on these data is solely that of the authors, and NCQA specifically disclaims responsibility for any such display, analysis, interpretation, or conclusion. Quality Compass is a registered trademark of NCQA. CAHPS® is a registered trademark of the Agency for Healthcare Research and Quality (AHRQ).