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    What providers need to do to improve chronic care


    Three chronic conditions where better patient engagement can impact health outcome are:

    •   Congestive heart failure

    •   Diabetes

    •   Chronic obstructive pulmonary disease (COPD)

    “Surveying patients is an effective chronic care strategy,” Hart says. “Automated surveys allow providers to monitor patients in their home environment, escalate cases where patients are at risk, and intervene before patients reach the point of needing acute care.”

    For example, to monitor patients with congestive heart failure (CHF), providers can assign a short touchtone survey to patients with this condition. A typical survey for this patient group would include less than 10 questions and be delivered to patients at home once or twice per week. After receiving an automated survey call, patients are directed to respond by pressing a number on their phone to answer questions about their current health status. Because weight gain can indicate problems in CHF patients, the survey might instruct patients to:

    •   Press 1 if they are at their usual weight

    •   Press 2 if their weight has increased up to 2 pounds from their usual weight

    •   Press 3 if their weight has increased three to four pounds from their usual weight in the past week

    Patients also might be asked to respond in a similar way to questions about their sleep, whether they are experiencing swelling, or having difficulty breathing.

    “The idea is to use known signs that indicate potential problems in CHF patients to identify issues before they turn into major problems for patients,” Hart says. “The data are then reviewed and, if the data show signs the patient is experiencing trouble, the healthcare provider can intervene early to prevent an acute situation.”



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