Strengthening long-distance care for chronic disease patients

Sara Berg, MS , News Editor

A new challenge has emerged during the COVID-19 pandemic: how to maintain care for patients with chronic disease. Many health systems and physician practices have cancelled or shifted nonurgent appointments and restricted access to office visits. Hospitals on the front lines are seeing a significant drop in heart attack and stroke cases, yet that doesn’t mean fewer people are suffering from cardiovascular events.  

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Instead, the fear of COVID-19 may be preventing people from going to the emergency department or calling their physician.  

“We recognize that in some locations right now or for some practices or specialties, acute care and dealing with patients with acute illnesses, particularly COVID, may need to be the number one priority,” said Kate Kirley, MD, a family physician and the director of chronic disease prevention at the AMA. “But I think for many physicians, including primary care doctors, a lot of practices have the capacity to continue caring for their patients who have chronic disease in many of the ways that they normally would, albeit a lot of that care can be delivered virtually.” 

With a growing need for health systems and physician practices to increase outreach, Dr. Kirley shares some tips for scaling chronic disease care during COVID-19.   

One way to reach patients with chronic diseases is to leverage telehealth resources. Virtual care offers an opportunity for physicians to touch base with their patients and address concerns while ensuring they don’t feel forgotten.  

“A lot of practices can continue to keep chronic disease appointments that they had on their schedules,” said Dr. Kirley. “Looking at those scheduled visits and reaching out to those patients and making sure that they get some type of virtual visit, whether it’s via telephone or video.”   

“Practices can also leverage their population health platforms right now to query those patients who are due for their chronic disease follow up,” she said. “Reach out to them and schedule them for virtual appointments just like they normally would.” 

Patients with chronic diseases may be at higher risk of complications from COVID-19, which contributes to the fear of leaving home for help when needed. This can lead to patients seeing their disease states deteriorate. Reaching out significantly changes that. While a simple check in seems basic, reaching out to patients with chronic disease to see how they are doing shows that physicians care and that it is still vital that they manage their condition. 

Learn more from the AMA about how to establish telehealth and deliver patient care while practicing physical distancing during the COVID-19 pandemic. 

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It is also important to ensure that healthy lifestyles do not fall by the wayside at home. Now is the time for physicians to continue to provide helpful tips for what patients can do at home to manage their hypertension, type 2 diabetes, obesity and other chronic diseases.  

“So much of the care that we deliver regarding chronic diseases is really about talking to our patients to see where they are,” said Dr. Kirley. “As always in medicine, nothing substitutes a good history and we can learn a lot just by having conversations with patients.”  

“We can supplement those conversations with data that we obtain virtually and self-measured blood pressure is a really good example of that,” she said, adding that this data then helps guide the management of their chronic condition. 

Additionally, “People are far more focused than they normally would be on what steps they can take at home to maintain their health or even get healthier right now,” said Dr. Kirley. “There is a lot that we can offer as doctors in counseling our patients that way.” 

Learn more about six lifestyle changes patients with prediabetes or obesity should make

Physicians can suggest digital offerings, such as virtual diabetes prevention programs that “can help people right now live their healthy lifestyles now that they’re all more focused on right now,” she said.  

Dr. Kirley suggests encouraging patients to expand their repertoire in kitchen. “It’s a great time to cook at home and try out healthy recipes that you normally wouldn’t otherwise do,” she said. “It’s a great opportunity to form new healthy habits right now.” 

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If physicians have capacity within their practice, their teams can be proactive about reaching out to patients who are higher risk to let them know that they have open lines of communication right now. Patients should be aware that offices are still answering the phones and scheduling virtual visits.  

It is important for physicians and their teams to know that they “can send direct mail and can send patient portal messages just letting people know we’re here. Please reach out to us if you have symptoms you’re concerned about,” said Dr. Kirley. “Of course, if a patient has severe symptoms, they should call 911.”  

“If anything, many practices right now have even more capacity, more availability, because their in-person schedules are canceled or significantly reduced,” she said. “We definitely want patients to know that now more than ever if you’re not feeling well, they really should reach out to their doctor and their doctor welcomes that.” 

The AMA has developed a COVID-19 resource center as well as a physician’s guide to COVID-19 to give doctors a comprehensive place to find the latest resources and updates from the Centers for Disease Control and Prevention and the World Health Organization.