Digital Chronic Disease Management solutions encompass integrated technological platforms and interventions designed to help healthcare organizations systematically monitor, treat, and support patients with long-term conditions such as diabetes, heart disease, and COPD. These solutions typically combine remote patient monitoring, data analytics, patient engagement tools, and care coordination features to enable proactive, continuous care management outside traditional clinical settings.
Chronic disease management — Key digital capabilities
Decision enablement and clinical intelligence | Empowers healthcare organizations to make data-driven decisions through advanced analytics, evidence-based protocols, and actionable insights that improve clinical outcomes.
Example companies: Innovaccer, Clarify Health |
Connected care delivery | Extends care beyond traditional settings through integrated virtual care and remote monitoring capabilities that enable continuous patient oversight and timely intervention.
Example companies: Vivify Health, WellSky |
Patient experience and engagement | Creates a comprehensive support system that empowers patients to actively participate in their care through personalized education, adherence tools, and seamless communication channels.
Example companies: WebMD Ignite, Medisafe |
Care team enablement | Streamlines clinical workflows and care coordination to maximize team efficiency while ensuring comprehensive documentation and appropriate reimbursement capture.
Example companies: Notable, ThoroughCare |
The case for digital in chronic disease management
Healthcare systems face mounting challenges in effectively managing their chronic disease populations, who account for 81% of hospital admissions, 91% of all prescriptions filled, and 76% of physician visits in the United States.1 These high-utilizing patients create significant operational and clinical burdens for health systems, with chronic disease care consuming approximately 90% of the $4.5 trillion in annual medical costs.2 Traditional care models struggle to provide the continuous monitoring and the personalized support these patients require, leading to preventable hospitalizations and strain on clinical resources.
Enabling continuous disease monitoring
Traditional episodic care models leave significant gaps between visits, making it difficult for health systems to detect and prevent patient deterioration. With 80% of serious medical errors involving miscommunication during care transitions, hospitals need more robust monitoring systems and patient touchpoints.3 Digital CDM solutions transform this paradigm by implementing continuous remote monitoring systems that track disease markers, symptoms, and medication adherence. Early detection and intervention capabilities have shown to reduce hospital readmissions among chronic disease patients.4 It is projected that systems deploying comprehensive CDM platforms can see upwards of $16,750 in savings for each hospitalization avoided.5 Organizations implementing comprehensive remote monitoring through digital CDM have also reported significant improvements in key clinical indicators for reduction in disease-relation hospitalizations.6
Optimizing clinical resource utilization
Healthcare providers face mounting pressures in chronic disease management, with more patients having at least one or multiple chronic conditions and chronic disease patients requiring more provider time than those with fewer to no chronic conditions, thus health systems need solutions that improve clinical workflow efficiency.7 Digital CDM solutions address this through automated documentation, streamlined workflows, and intelligent task prioritization. Healthcare organizations implementing comprehensive digital CDM solutions can leverage intelligent analytics to enhance resource allocation and clinical workflow efficiency, enabling care teams to effectively manage larger patient panels while maintaining high-quality care delivery through data-driven prioritization and automated care management tools.8
Driving revenue and risk management
Healthcare systems face significant financial pressures in chronic disease management, with over 2,000 hospitals receiving readmission penalties under the Hospital Readmission Reduction Program (HRRP), totaling $2 billion in penalties.9 These penalties particularly impact hospitals serving complex chronic disease populations, who are more likely to be readmitted within 30 days of discharge.10 Additionally, health systems struggle to comply with Chronic Care Management (CCM) billing code requirements that capture available chronic care management reimbursement, resulting in incomplete payments for the services they have provided.11 Digital CDM solutions address these challenges through comprehensive monitoring and engagement to improve patient outcomes and meet reimbursement requirements. Organizations using these platforms report the opportunity to generate an additional $150,000-352,500 in direct revenue annually while preventing potential readmissions through early intervention.12
Sources
- https://www.fightchronicdisease.org/sites/default/files/docs/GrowingCrisisofChronicDiseaseintheUSfactsheet_81009.pdf
- https://www.cdc.gov/chronic-disease/data-research/facts-stats/index.html#:~:text=Ninety%20percent%20of%20the%20nation’s,chronic%20and%20mental%20health%20conditions.
- https://pmc.ncbi.nlm.nih.gov/articles/PMC3312531/#:~:text=According%20to%20the%20Joint%20Commission,of%20hospital%20patient%20safety%20culture.
- https://www.cms.gov/about-cms/agency-information/omh/downloads/omh_readmissions_guide.pdf#:~:text=There%20are%20well%2Dknown%20clinical%20interventions%20and%20care,follow%2Dup%2C%20are%20necessary%20to%20decrease%20readmission%20rates., https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2794153
- https://www.medsien.com/articles/saving-the-system-remote-care-management-programs-bring-major-cost-savings-by-improving-care-and-reducing-hospitalizations
- https://www.jmir.org/2023/1/e46439/
- https://pmc.ncbi.nlm.nih.gov/articles/PMC9881650/#:~:text=47.272)%20in%202050.-,Of%20the%20population%2050%20years%20and%20older%2C%20the%20number%20with,multimorbidity)%20from%202020%20to%202050., https://www.aha.org/system/files/content/00-10/071204_H4L_FocusonWellness.pdf, https://pmc.ncbi.nlm.nih.gov/articles/PMC1466884/#:~:text=On%20the%20other%20hand%2C%20the,patients%20with%20fewer%20comorbid%20conditions., https://pmc.ncbi.nlm.nih.gov/articles/PMC9848034/#:~:text=calculated%2010.6%20h/day%20were,the%20top%20ten%20chronic%20diseases.&text=These%20studies%20suggested%20at%20least,providers%20in%20providing%20patient%20care.&text=Many%20healthcare%20organizations%20have%20encouraged,and%20with%20team%2Dbased%20care.
- https://welkinhealth.com/benefits-of-healthcare-automation-for-patient-care/
- https://www.advisory.com/daily-briefing/2022/11/04/hrrp-penalties, https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.05412#:~:text=To%20date%2C%20over%20three%2Dquarters%20of%20participating%20hospitals%20have%20been%20penalized%20by%20the%20HRRP%2C%20with%20total%20Medicare%20penalties%20reaching%20%242%C2%A0billion.6%E2%80%938
- https://pmc.ncbi.nlm.nih.gov/articles/PMC7659222/#:~:text=Risk%20factors%20of%20readmission%20to,2%2C%205%2C%207%5D., https://www.heinz.cmu.edu/media/2020/March/new-way-to-identify-patients-could-reduce-future-readmissions#:~:text=Studies%20show%20that%20patients%20with%20multiple%20underlying%20chronic%20conditions%20are%20more%20likely%20to%20be%20readmitted%20to%20hospitals%20within%2030%20days%20of%20discharge%20than%20those%20without%20chronic%20conditions.
- https://www.signallamphealth.com/overcoming-barriers-to-an-effective-ccm-program/,
https://federal-lawyer.com/chronic-care-management-ccm-is-now-a-doj-enforcement-priority/#:~:text=Common%20CCM%20Billing,or%20the%20DOJ., https://pmc.ncbi.nlm.nih.gov/articles/PMC5698215/#:~:text=The%20barriers%20to%20CCM%20range,and%20maintenance%20of%20care%20plans. - https://www.thoroughcare.net/blog/care-management-programs-revenue, https://care-harmony.com/hospitals-chronic-care-management-ccm-and-transitional-care-management-tcm/, https://drkumo.com/chronic-care-management-prevents-hospital-readmissions/#:~:text=CCM%20ensures%20that%20a%20patient’s,take%20swift%20action%20when%20necessary., https://www.ecaremd.com/blog/reducing-hospital-readmissions-with-chronic-care-management-software/#
