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Caring for patients with multiple chronic conditions requires identifying those at risk, clear communication, and coordinated care to improve outcomes.

Approximately 60% of American adults live with at least one chronic condition, and 40% of them have more than one. Many of these patients are clinically complex and receive care from multiple professionals—which creates unique management hurdles. It takes more than just a physician’s clinical expertise to achieve optimal outcomes for these patients; it also requires effective communication and care coordination to ensure that physicians receive all the information necessary to care for their patients.

It’s easy to understand why communication barriers can hinder care coordination between primary care physicians (PCPs), specialists, hospitalists, and professionals at other facilities. For example, although documenting in the electronic health record (EHR) can improve access to organized information, a lack of EHR interoperability may hinder communication among physicians who use disparate EHR systems.

Regularly, specialists have to ask patients to explain why their PCPs referred them, and few specialists still send “courtesy” notes to PCPs after a consultation. Even within practices, some staff members may not be aware of which patients require more proactive management due to multiple chronic conditions. While technology can help make patient information more visible and care coordination more seamless, opportunities for improvement exist.

Therefore, it’s not much of an exaggeration to say that most of the battle for quality health outcomes for patients with multiple chronic conditions rests on identifying needs, establishing open communication, and coordinating care.

The 3-legged Stool: Identify, Communicate, & Coordinate

Leg #1: Identify

Better care coordination begins with identifying which patients require it the most. Fortunately, technology can help us identify patients with multiple chronic conditions, as well as gaps in care and other factors that may increase their risk for worsening health conditions.

For example, many population health management tools can run reports that identify patients who:

• Have not been seen by their PCP in a year (and thus aren’t engaged in their care or completed preventive exams).
• Have open gaps in care or medications not filled.
• Have clinical indicators of disease complexity or advancement.

These types of reports can help identify patients with multiple chronic conditions who may be at a higher risk for an emergency department visit or hospital admission.

Leg #2: Communicate

To be truly useful, however, the data must journey from population-level reports to information that physicians, advanced practice professionals (APPs), nurses, and others engaged in direct patient care can use. If the first leg of the proverbial stool is understanding which patients have multiple chronic conditions and need attention, the second involves communicating that knowledge to the care team.

To move information from a report to the point of care, physicians can:

• Train staff to use reports before scheduling. Understanding which patients need more immediate care or more frequent visits to better manage their chronic conditions can help prioritize their outreach efforts.
• Ask staff to pull reports each afternoon for the next day’s patients. Staff should note if patients are on any lists, such as those mentioned above. They should also try to obtain the results of any exams, tests, or consultations that aren’t yet in the chart.
• Conduct a daily morning huddle. Ensure the conversation addresses any care coordination needs, quality gaps, or other concerns identified by the data that may impact treatment decisions, referrals, or patient education opportunities.
• Communicate clearly with appropriate non-clinical staff. For instance, schedulers who are aware that a patient needs more frequent visits or is at risk for hospitalization can prioritize appointments accordingly.

Of course, none of these strategies will improve outcomes if patients don’t come into the practice for care! So, patient communication is equally vital.

Ideally, some patients with multiple chronic conditions should be seen every month or two. We’ve found that the beginning of each year is an excellent time to conduct proactive outreach and engage patients in their care. We contact any patients not seen in the practice the previous year and then use reports to prioritize reaching out to those patients who are more at risk based on the data.

Leg #3: Coordinate

Even with excellent reports and communication, few physicians can manage such complex patients alone. That’s why care coordination is the final leg on which success rests. Some suggestions for strengthening care coordination include:

• Enlist the aid of any patient support programs that are available, such as social work or case management teams, local community-based organizations, or vendor programs.
• Consider creating a care collaboration compact with specialists. For example, one physician in South Texas offers a letter to specialty professionals that outlines how each party—she and the specialist—can communicate more effectively, develop care plans, and collaborate to ensure high-quality care for their mutual patients.
• If you are part of a larger professional organization, hold regular quality meetings with other physicians to trade best practices.
• Access hospital patient records through courtesy privileges and ADT feeds.

Transforming Patient Care

Whole-person care requires a holistic view of each patient, which few physicians typically possess when treating patients with multiple chronic conditions. Therefore, even if effective chronic condition management starts with data, it certainly doesn’t end there.

It truly takes a village to overcome the obstacles and ensure optimal patient outcomes. In our experience, it’s not helpful to simply throw data at physicians. However, when data is paired with ongoing communication and robust care coordination, the results can be transformative.