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A Guide to Chronic Care Management with CRM

By 05.26.21 chronic care management
Reading time: 4 minutes

Six in ten adults in the United States suffer from chronic disease, according to the CDC

Four in ten adults live with two or more chronic illnesses.

Americans spend about $1.8 trillion on the management and treatment of chronic diseases such as asthma, diabetes, cancer, and heart disease each year.

By definition, chronic diseases are long-lasting, the types of illnesses that persist throughout a patient’s life. Many chronic health conditions have no cure, only ways to manage symptoms.

Many of the most common contributing factors of chronic disease include lifestyle behaviors such as poor nutrition, tobacco use, excessive alcohol consumption, and lack of physical activity. Because modification of these behaviors is a key element to improving health, and thereby controlling costs, healthcare professionals need new ways to help their patients better manage their disorders and lifestyle.

That’s where CRM technology like Salesforce can help.

5 ways CRM helps providers with chronic care management

To help balance care in and out of the doctor’s office, providers should empower patients to take more control over their health. By supplying the tools and knowledge to help chronic disease patients measure and monitor themselves, clinicians can equip them to improve their outcomes in the comfort of their home.

Many health systems and physician practices have begun to leverage CRM platforms, such as Salesforce, to support and educate patients. Here are some ways to empower chronic disease patients to manage their care:

1. Identify and enroll patients in specific initiatives 

Salesforce can collect and analyze significant amounts of data from patients, to easily identify and then enroll patients in specific chronic-care or population-health management programs. Powered by Tableau CRM analytics, providers can identify a panel of patients based on various criteria and risk algorithms and enroll them into a care management program to ensure they do not fall between the cracks.

2. Encourage early detection through preventative care

By promoting preventative care before the patient even arrives at the doctor’s office, health systems and providers can minimize the number of patients who are faced with chronic diseases because of poor health choices. To effectively communicate with a broad patient population, Salesforce can help identify patients who are due for annual, preventative care such as:

  • Critical screenings (e.g. mammography, prostate, etc.)
  • Flu shots and immunizations
  • Prenatal and postnatal care
  • Physical scheduling and other regular check-ups

You can set up protocols to send an automated text or email to patients based on their condition or last visit date. Proactively delivering these messages gets patients in the door before it is too late. And, when a patient deviates from their care plan, responses to automated text can inform the care team, allowing them to intervene in a timely manner.

3. Deliver educational communication regularly

Beyond preventative care reminders, healthcare systems and providers can empower chronic disease patients to manage their care by continuing to communicate with them outside of the doctor’s office. Patient communication could be tailored for a variety of common chronic conditions, including for example:

  • Asthma, diabetes, congestive heart failure (CHF), coronary artery disease (CAD)
  • High-risk obstetrics
  • Obesity and smoking cessation

Automatically generate educational resources and message frequency based on clinical data and criteria. This improves compliance to care plans and proactively connects chronic disease patients to the right resources at the right time. For example, Salesforce allows you to collect and analyze data related to how well a diabetic population responds to specific exercise or medication interventions. As such, caregivers can identify and adopt best practices.

A steady stream of wellness tips and lifestyle reminders sent via text can also encourage chronic disease patients to make long-term changes to their health habits.

4. Coordinating care among multiple providers across the continuum

Salesforce connects various care providers to one another, enabling multiple caregivers to collaborate on care for one patient, thus making it possible to truly work as a team to produce optimal outcomes.

With Salesforce, data is so much more transparent. Various providers – whether they are a physician employed by the hospital or a private care physician – can access the same data and work together with a 360-degree view of the patient. 

This helps teams go from dealing with one specific symptom at a time (say, a neurologist and a physical therapist for MS patients) to taking a holistic view of the patient to deliver the best possible care. 

5. Boost patient portal engagement

In addition to automated patient outreach, patient portals can be a great tool to ensure consistent communication between providers and their chronic disease patients. It puts all the information patients need right at their fingertips, including medical history, upcoming appointments, and self-scheduling tools.

Patient portals are especially useful for patients juggling complicated treatments and medications, as providers can send direct educational material to patients and alert them of new options as they arise. Patients can also leverage the patient portal to check in with their providers when they are experiencing a symptom of their condition to see if there is an adjustment they can make at home or if their issue warrants a visit to the doctor’s office. 

Applying the patient’s preferred communication preference — automated phone, email, or text message alerts — effectively reminds patients to take medications, eat healthy, or monitor blood pressure and weight. Additionally, more and more organizations are utilizing online chat options to establish a simple way for patients to communicate with healthcare providers. 

Improve patient outcomes with CRM and Silverline

When patients are engaged in managing their care, they’re more likely to adhere to care plans, track key metrics of their health, and reach out to their doctor when they have questions. Each of these behaviors can help chronic disease patients improve their outcomes, or at the very least, prevent their illness from escalating. 

Silverline’s deep expertise in the healthcare industry can help providers provide a framework for developing programs to address chronic disease management and close gaps in care. Silverline can help organizations build the tools to manage referrals, perform nurse triage, manage a provider network, manage a risk-based population, and much more.

From strategy and implementation to managed services, we guide clients through every phase of their journey — enabling continuous value with the Salesforce platform. Learn more about how Silverline can help you provide better chronic care management for your patients.


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