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Keeping connections in a distanced world to transform chronic care

June 23, 2020 | Condition Management

An older female with silvery, long hair eats a bowl of fruit in her kitchen while using a tablet computer to access digital health services.

By Jonathan Mayhew, Executive Vice President, Chief Transformation Officer, CVS Health

Four months ago, chronic care was one of the nation’s biggest health challenges, affecting more than half of all American adults and driving 90 percent of health care spending according to the Centers for Disease Control and Prevention. Four months ago, new tools for helping people better manage and even prevent chronic conditions were expanding our ability to reach people early and often, connecting them with our local care teams, local community resources and virtual capabilities to support everyday decisions between regular doctors’ visits. Whether individuals chose to seek support at home, at work, in the pharmacy, online, or through a combination of all these options – these increased connections and intervention in chronic care would help prevent emergency room visits and hospital readmissions, improve health outcomes and lower costs.

Today, I still believe increased support and connections are key to fighting chronic disease, which is still a top health care challenge. But our world is different in many ways than it was four months ago. We are managing and looking to recover from a grueling pandemic, which has disproportionately impacted minority and underserved populations. Many people with chronic conditions have already delayed care due to fear of contracting COVID-19 in a health care setting. In the months ahead, stopping in at your local pharmacy or visiting a doctor may not sound as appealing as it once did. For some, it will be non-starter.

At CVS Health, we understand that. Still, it is critical for those suffering or at risk of chronic conditions to continue regular care. And our approach to helping individuals with chronic conditions, which includes innovative touchpoints and groundbreaking data analysis, reflects the evolving needs of our customers, including a new reality shaped by the pandemic.

Combining physical, digital and virtual for more support options

Our past and real-time experience tells us that, particularly during stressful times, individuals at home need expanded options for accessing support for everyday decisions related to diet and exercise as well as medical and behavioral health care. While we will continue to expand our brick-and-mortar HealthHUB® locations to provide in-person health and wellness care, pharmacy services and retail goods, we also are accelerating and expanding our digital presence and integrating new virtual capabilities into our care management programs.

Recently, we have expanded the ways customers can engage with a CVS pharmacist, MinuteClinic® clinicians, or HealthHUB concierges (where available) to receive services. So, while an individual may not travel to see her pharmacist – she can still speak live over the phone or engage through an app and, afterward, have her medications delivered to her home. Additionally, through expanding telehealth capabilities, many individuals can access doctors to address medical and behavioral health concerns. No matter their preference, individuals have an array of options to stay connected.

Within our care management and condition management programs, we are making sure that, in addition to traditional telephone support, care managers can provide support using telehealth services and, when it is deemed safe to do so, still visit with individuals in their homes.

Data is the game changer

Data will make these options even more effective. In the past, when the topic of data and analytics was raised related to care or condition management, it typically meant relying on claims data exclusively. Today, CVS Health is not only able to bring together a broader set of data from prescription claims and medical claims, but we also combine that data with lab results, electronic health record data and information from medical devices and wearables where permitted. As we’ve seen in Korea and multiple other countries, along with some efforts in the U.S. to track COVID-19, this approach provides a much more comprehensive understanding of what is happening with an individual and within a community. And because we are able to aggregate and analyze this data in real time, the insights we can generate for care managers, nurse practitioners, pharmacists and doctors (as part of referrals and ongoing care coordination) are actionable and make health care simpler for individuals. This kind of data fuels our Pharmacist Panel program which notifies our pharmacists of potential gaps in care or preventive care opportunities based on medical, pharmacy and lab data. This expanded view makes it even easier for pharmacists to proactively engage members in relevant, impactful and timely one-on-one conversations about how best to manage their chronic conditions. And this outreach is delivered through member-preferred channels like text, email or telephone.

Moving to a comprehensive approach to condition management

Unmatched data and multiple connection capabilities allow CVS Health to break away from the one-size-fits-all approach to chronic condition management. For example, most diabetes management programs today focus on just two modes of support -- monitoring blood glucose and managing issues of lifestyle and comorbidities – mostly through virtual reporting and telephone coaching.

Our comprehensive approach to diabetes care for Aetna members and CVS Caremark customers focuses on three additional areas for a total of five impact areas. In addition to monitoring blood glucose and managing lifestyle issues, we aim to ensure individuals also are receiving the recommended annual health screenings, adhering to medications and taking the right medications to manage their diabetes and any other conditions. Whether an individual is seen by a CVS pharmacist, a care manager, or MinuteClinic nurse practitioner online or in person, each will have an integrated view of the individual’s health needs in these five clinical impact areas. They will all be on the same page regarding medications, test results and care plans. This not only leads to more effective management of diabetes and other chronic conditions but also reduces the frustration patients often experience when care is disconnected and uncoordinated.

Taken together, improved interactions and data-fueled insights paint a picture of complete end-to-end condition management with many options for engagement and support. That is what is needed to improve our standard of care for diabetes and other chronic conditions. With integrated care teams, digital and virtual solutions and data technologies, we can stay connected to more people, on their terms and comfort levels, and help them to more successfully manage their chronic health conditions today and well into the future.