Mythbusters: Debunking the Fallacy that Chronic Disease Ends after Transitional Care

Without chronic care management, readmissions are more likely to follow transitional care

Successful transitional care after an acute episode can give patients and their doctors a false sense of security for one simple fact: chronic illness almost never goes away entirely.

An increasing body of research shows that chronic care management after an acute episode is the gold standard for preventing costly readmissions. However, providers often make the mistake of closing the books when their patients finish transitional care after an acute episode. They treat it like a graduation ceremony. 

This is a big reason why chronic disease still consumes more than 75% of this nation’s health care spending and remains the leading cause of death and disability. 

Providers often treat acute chronic disease episodes in a vacuum, and fail to trigger long-term maintenance plans that prevent them from happening again. At this point, most providers understand the value of chronic care management, but they lack the technology and trained staff to roll out longitudinal care plans at scale.

It’s an unfortunate reality, especially when we’ve seen the kinds of early interventions borne out by effective care management models. A study this month in the journal Respiratory Care found readmissions for chronic obstructive pulmonary disorder (COPD) dropped by roughly half for patients who had access to at-home interventions when compared to a control group.

The study looked at home visits by a respiratory therapist; however, the framework for those visits bears striking resemblance to the work CCM Signallamp’s remote nurses do every day. 

“Patient health coaching can improve treatment compliance as a key component of self-management approaches,” the researchers wrote.

To qualify for CCM, patients must have two or more conditions that they expect to have for at least one year or until death. For patients with the most prevalent chronic illnesses like heart disease, high blood pressure, diabetes and cancer, their illnesses will follow them for the rest of their lives. Chronic disease patients don’t graduate from the health care system when they leave the rehab center, but they can learn to adapt to their disease, get it under control and thrive through it.

It means daily maintenance and mindful diets, even after symptoms or diagnostics show the disease is well controlled and symptoms stay on the margins. It means medication compliance and honesty with providers. Those aspirational goals come so much easier when each patient has an eager partner — a dedicated nurse case manager to guide them through their journey with chronic illness.

Here’s how CCM keeps patients on track after transitional care

Chronic Care Management provides a baseline of medical attention. It does not disrupt patients’ daily lives because it all happens by phone. It connects the dots between their changing conditions and the physicians’ offices that mitigate them. There are three key reasons why enrolling in CCM needs to be a part of every transitional care plan.

Routine 

First, it leads patients toward a routine and raises guide rails to keep them from falling off. Those guide rails start with 20-minute phone calls every month with a registered nurse. As patients learn to trust their Signallamp nurse case manager, they lean into them more. 

Trust

We mentioned honesty earlier. Without trust, there’s no honesty. While bridging the gap between office visits every month, CCM nurses learn things about their patients behaviors, medication compliance and symptoms because patients learn to trust the routine.

Interventions

This can lead to powerful, yet simple interventions long before symptoms get out of hand. One of our favorite stories is how one patient, who had been testing high for A1C blood glucose levels every morning, ultimately confessed to sneaking midnight snacks after her husband went to bed. We all can agree that guiding a behavior change is far more convenient — and far less expensive — than rushing to the hospital for acute hyperglycemia.

Accountability

More than any other disease category, chronic illness responds to lifestyle. It retreats when we find a healthy, effective routine and stick with it. But changing behavior is difficult, even for the strongest of us. Chronic care management nurses, who mostly come from clinical settings, bring a nurturing spirit to bear on tough topics like medication compliance, wholesome diets and exercise regimens.

Schedule a call to see how Signallamp Health nurses prepare your chronic populations to manage their symptoms long term.

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