In anticipation of a Covid-19 surge, many health systems have had to rethink care delivery, including canceling or shifting non-urgent appointments and restricting access to entry points. While these are necessary steps to expand capacity, they disrupt or delay care for non-Covid-19 patients with chronic conditions—many of whom are also at a higher clinical risk of Covid-19.

How 15 organizations successfully manage patients with chronic diseases

The challenge is: because complex patients aren't able to readily access care, many health systems are in the dark about their needs and how to best manage their care. And in addition to clinical risk factors, comorbid patients may have social needs that are being amplified by the epidemic.

In response, health systems should proactively scale up outreach—and recognize that many "rising risk" patients may now need a more intensive level of support. Below, our suggestions for scaling chronic disease care during Covid-19.

Reconsider who your 'high priority' patients are

Generally, health systems rely on utilization data to pinpoint high-risk patients, but many of these patients are no longer seeking ED care or regularly meeting with their care team. In absence of this information, you may need to turn to other indicators to identify patients who are facing exacerbated barriers to self-management, such as:

• Patients who live in highest-risk and -cost areas: Geotargeting can be used to identify at-risk patients in geographic areas who have faced significant job loss, housing instability, or a high incidence of Covid-19 cases.
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• Patients with behavioral health needs: Early findings indicate that the Covid-19 crisis can exacerbate mental health symptoms. Patients with behavioral health diagnoses may also experience disruptions in their treatment. Both make self-managing chronic conditions more difficult.
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• Patients who aren't "showing up": Reach out to patients who unexpectedly or repeatedly cancel virtual or phone check-ins with their care team. And monitor patients for other deviations from care, like failing to pick up prescriptions or complete lab work.

When checking in with these patients, take time to discuss their individual concerns and questions about Covid-19, and identify any obstacles the situation is presenting to their health. For instance, set up delivery for medications and educate them on who to call if they present any Covid-19-like symptoms. 

Provide ongoing support for chronic disease management

In addition to reprioritizing outreach, consider ways you can scale support for high and rising risk patients. Telephonic support is a viable alternative to in-person care for rising-risk patients who aren’t proficient in digital self-management tools but would still benefit from additional check-ins and education reinforcement. High-risk patients may benefit from more in-depth telehealth support, such as remote monitoring, to prevent avoidable hospitalizations.

Many health system leaders have voiced concerns about a looming influx of complex patients who are struggling to manage their chronic conditions during the Covid-19 crisis. By focusing outreach on "high-priority" patients and proactively scaling support, health systems can mitigate demand. Doing so can reduce both the need for immediate acute-level care that puts patients at risk of infection as well as an increased demand post-surge.