Managing Chronic Conditions And Acute Health Episodes

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Anne is a 67-year-old patient with diabetes. A couple weeks ago she had hip replacement surgery and then was transferred to a skilled nursing facility (SNF) to start her rehab. The initial rehab went well, and she was sent home a few days ago. Before the surgery, Anne was told not to take her oral diabetes medication the morning of the procedure. However, Anne is not sure when she can start taking the medication again. No one at the SNF said anything to her, so she has not taken any since. It’s probably fine, she thinks. They would tell me if I should be taking medicine again

While this patient is fictitious, the scenario is real for many Americans: 6 in 10 adults in the U.S. have a chronic disease, with 4 in 10 having two or more chronic diseases. Many people take medication to manage chronic conditions, but they may have their medications changed during their hospital stay. A study of 2,655 patients found there were over 10,000 medication changes at hospital discharge, one in four of which was not followed. When an acute health concern occurs, how does the care team ensure that both the acute and chronic concerns are being addressed? 


Communication impacts patient outcomes. Good communication has been associated with improved health outcomes, while communication errors contribute to between 50% and 80% of sentinel events. Communication is especially important during transitions of care. There is often miscommunication among clinicians during the transition from acute care to a SNF, which negatively impacts patient outcomes. One study found that for patients moved to a post-acute care facility after a hospitalization, 22.8% had at least one hospital readmission. For the scenario above, do the clinicians at the SNF know Anne usually takes diabetes medication? Does Anne’s primary care provider know Anne has stopped taking the medication? This could seriously impact Anne’s health. 

There are many strategies clinicians and healthcare organizations can use to improve communication. One strategy is to reduce clinicians’ workload so they have ample time to communicate with others. In 2018, 70% of physicians said they spent over 10 hours per week on administrative work, with 32% saying they spend over 20 hours per week on it. This administrative load on top of clinical responsibilities means clinicians are pressed for time, and sometimes that time is taken away from proper communication. To reduce the workload, organizations can block patient appointment times specifically for clinicians to use for administrative work and documentation. Another strategy is for organizations to invest in technology that reduces administrative work, giving clinicians more time to spend with patients and to communicate with other members of the care team. 

Task Management for Co-Occurring Health Concerns

It can be difficult to manage an acute care problem along with chronic conditions. From a patient’s perspective, this can mean a lot more work to manage their health with less energy. For example, for Anne’s diabetes, she is supposed to take her daily medication, carefully monitor her diet, and test her blood sugar regularly throughout the day. With the surgery, Anne has a lot of rehabilitative exercises she needs to do multiple times each day. Additionally, in the early stages of her recovery, it has been more difficult for her to move around, and she is tired from the extra effort required to do simple things. It’s easy to forget to check her blood sugar, or to just grab the ice cream out of the freezer instead of cooking dinner. 

It can also be difficult to manage tasks from a clinician’s perspective. Let’s say Anne goes to her primary care physician for a follow-up. The physician has a lot of questions to ask Anne about the surgery, such as how she is able to move around and her pain level. The physician should also ask Anne about many aspects of her diabetes, such as her medication, her specialist appointments, her diet, her blood sugar monitoring, and more. In a short 15 minute appointment, it can be hard to discuss all these items, or to even remember them all. Additionally, the physician may assume that the endocrinologist has asked Anne about diabetes management, or the physician may forget to ask Anne about her medication, meaning Anne continues not to take it. 

Technology can help manage tasks among a team of clinicians. For example, when the primary care physician learns Anne is having surgery, the physician can add tasks so that in Anne’s first appointment after surgery, the physician remembers to ask Anne how often she is testing her blood sugar, go over any medication changes, and remind Anne to schedule her ophthalmology appointment. If this task list is shared with the endocrinologist, then the PCP can see that the endocrinologist already asked Anne about specialist appointments, and can see that Anne has an ophthalmology appointment scheduled three weeks from now. Collaboratively managing tasks helps the entire care team work together so that chronic disease management doesn’t slip through the cracks