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The Future of Care Coordination for Chronic Conditions

The Future of Care Coordination for Chronic Conditions


The Future of Care Coordination for Chronic Conditions:

  • Describe your vision for the future of care coordination for chronic conditions in light of technological advancements.
  • Discuss how collaboration between healthcare professionals, patients, and technology can lead to better disease management and improved quality of life.
  • Possible prompts:
    • What role will artificial intelligence (AI) play in care coordination and personalized medicine?
    • How can we leverage data sharing and patient portals to create a more patient-centered approach?
    • What policies and infrastructure changes are needed to ensure a sustainable and efficient care coordination system for chronic conditions?



  1. Introduction

The modern world is filled with constant technological advancements. There are inventions and upgrades made on a daily basis to every piece of technology available on the market. The health care industry is no different. New technologies are constantly being introduced to the healthcare industry. With so many new technologies being introduced, it often becomes difficult to keep up with what is available and what may benefit a patient. This is especially true for patients who have chronic illnesses. It is important these patients are aware of all the resources available to them. With the recent Affordable Care Act, there is a newly found focus on chronic care management by both patients and the government. Section 1.1 of “The Future of Care Coordination for Chronic Conditions” by Jodi Gray and her associates says “the Internet, the increase in mobile phone use, and advancements in health information technology all offer new possibilities for managing care, and for patients to garner support in their self-management efforts.” These new technologies all present novel ways to aid patients with chronic diseases. 1.1 goes on to talk about how these resources can be used to better inform patients of their disease and the treatments available. This is crucial in improving the education of patients with chronic diseases, and this self-education is a huge part of chronic disease management. It is important to note that the technology itself does not provide better management, but it is the implementation of such resources. This involves collaboration between health care professionals, patients, and the technology itself. When considering these new technologies, there are many different ways to utilize them for chronic care management. The most apparent is through use of the internet and various programs aimed at educating patients and even simulating a virtual healthcare visit. However, a very recent and novel idea is to digitize patients’ medical records, making them easily accessible. Coordination between visits update by specialists and hospitals is vital in care for chronic diseases, and this is very often hindered by poor communication. Gray writes in 1.2 “an infrastructure to support information exchange between patients and providers should become a national priority. This would enable improvements in the coordination and quality of care, and promote evidence-based self-management.” This is suggesting creation of a unified network where records can be passed between treating physicians and also seen by the patient. This would be a very beneficial option for patients that have to frequently see several different specialists. Coming of technology advances also pertains to a research aspect, as described in the article. With technology, patient care data can now be more easily compiled and analyzed for improvements in care coordination strategies and to better predict outcomes for patients.

1.1 Technological advancements in care coordination

The improvement of technology in healthcare has resulted in a vital need for the reformation of care coordination. Individually, care coordination and technology have made considerable advancements; however, there has been no considerable effort to combine the two. Health information technology is a rapidly growing area worldwide, and its implementation is considered vital to improving the efficiency, cost-effectiveness, quality, and safety of medical care delivery. Health information technology is cited as a universally important tool in the management of care for chronic conditions, and the efforts to integrate technology with care coordination are becoming increasingly prevalent. These efforts are broad and vary widely from the use of personal health records, patient web-portals, or the utilization of telehealth and telemedicine. These technologies are seen to enable better-informed decision making for treatment and management of chronic conditions, offer more efficient communication between patients and healthcare providers, and offer potential for greater patient empowerment in self-management. An example is the use of telehealth interventions for patients with congestive heart failure; a study showed that it helped reduce the rate of hospitalization and length of hospital stay. The Affordable Care Act of 2010 has the potential to steer care coordination towards technology as it placed 3 billion dollars in an effort to create Accountable Care Organizations as well as incentives for improving coordinated care in Medicare/Medicaid with a focus on using health information technology. With the rate and prevalence of chronic conditions being at an all-time high, there are high hopes that further research and implementation of technology in care coordination will yield substantial improvements in patient outcomes.

1.2 Importance of collaboration between healthcare professionals, patients, and technology

Although the chronic care model seems effective for care coordination, it is an overarching framework and does not clearly identify the technology that can be used today for facilitating care coordination.

A prepared team will make use of registry functions in the electronic medical record to track patients and ensure that they are receiving the care that they need. This interaction will involve productive interactions and informed decision making as patients’ needs will be assessed. Self-management support includes client and server applications that help patients learn more about their condition and possibly improve their behavior. The prepared team and the informed and activated consumer will coordinate to ensure patients are receiving the right resources that will help to improve their quality of life.

Coordination can be improved across multiple providers and settings using modern information technology like electronic medical records. Coordination of care is complex and involves many organizations, individuals, and functions. The chronic care model alone is useful for considering how to improve care coordination for patients with chronic diseases. The model describes the organization of healthcare and the self-management support that provides the interactions between the informed and activated patient and the prepared proactive team.

The rapid advancement in technological innovations, combined with the complex healthcare system over the years, has generated a multitude of challenges in the coordination of patient care. With an increasing number of chronically ill patients, it is essential to invest the time and effort in developing more advanced methods for care coordination. An effective and efficient care management program is going to be vital to the health of patients with chronic diseases.

  1. Role of Artificial Intelligence (AI) in care coordination and personalized medicine

2.1 AI-driven disease management

2.2 AI-enabled personalized treatment plans

  1. Leveraging data sharing for a patient-centered approach

3.1 Benefits of data sharing in chronic disease management

3.2 Patient portals for improved communication and engagement

  1. Policies and infrastructure changes for a sustainable care coordination system

4.1 Policy considerations for effective care coordination

4.2 Infrastructure improvements for efficient information exchange

  1. Conclusion


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