Prior to Covid-19, the U.S. healthcare system was already struggling to respond to a persistent and growing epidemic of type 2 diabetes, hypertension, heart disease, and other chronic conditions, often co-presenting with mental health problems such as depression and anxiety. Chronic conditions have risen sharply over the past 50 years, affecting 133 million Americans and now account for 90% of our $3.5 trillion annual healthcare spend.
The chronic disease epidemic in the U.S. is rooted in recent culture change, including a huge shift in our nation’s food supply and daily living environment that strongly shape everyone’s lifestyle habits. Our bodies are highly stressed by processed foods and sugar-sweetened drinks, salt, and the industrial chemicals being put into what we routinely eat and drink. Many people lack access to healthy foods. Sedentary living, information overload from digital devices, and a disconnect from nature in everyday life contrast sharply with the natural environments we evolved from.
The human immune system is designed to have a potent and effective acute response to armies of invading microbes and physical insults. It resets itself to normal after repairs are made. The stress of modern living is constantly activating this system, causing insulin resistance, hypertension, atherosclerosis in our blood vessels and disruption of our complex natural biological systems. The term “chronic low-grade inflammation” is now used routinely in medical journals to describe this phenomenon – a persistent, smoldering system-wide immune response to emotional stress, poor nutrition, and chemical irritants.
Coid-19 has added a new, acute immune response (a “cytokine storm”) to this long-standing immune disruption problem stemming from obesity and unhealthy lifestyle choices. What’s more, we are now learning that many Americans who hunkered down over the past year to avoid infection report that their diet is even poorer, they feel more isolated, and are experiencing higher levels of additional stress from Covid-19. Research shows that we can expect a greater wave of death and disability from chronic diseases due to these factors – compounded by the fact that many patients have also avoided regular medical checkups for chronic conditions.
This pandemic has shown us the importance of thinking in terms of overall population health, not just our individual health. The U.S. had one of the highest rates of complications and deaths from Covid-19, in part because of the poor underlying health of its population. To date, the U.S. healthcare system’s management of the pandemic has been largely focused on pharmaceutical and medical interventions.
We now have an opportunity to stop and reflect on not only the condition of our national health but also to consider how we might radically adjust our approach to healthcare, particularly our investment in chronic disease management and prevention.
The critical role of self-management skills and social determinants of health in engaging patients and families.
Lifestyle-related chronic diseases are mostly preventable or reversible. Yet, this requires lifelong effort on the part of the patient to remain healthy. The U.S. healthcare system is hyper-concentrated on acute care and medical treatments, which research shows drives only 10% of individual health outcomes. Another 30% of health outcomes are attributed to genetics. The real opportunity is to positively influence the 60% of health outcomes attributed to individual behaviors and social and environmental factors, including the way we eat, move, sleep, manage stress, and our social relationships.
With a focus on acute care, there has been an underinvestment in exploring and addressing the primary drivers of poor health, namely daily self-management behaviors and psychosocial barriers for people with conditions where the patient needs to do most of the work of carrying out the treatment plan, such as with type 2 diabetes and hypertension. To effectively treat chronic disease, we need to understand an individuals’ experience living with a chronic condition and make sure treatment plans are built in a way that addresses a patient’s current behaviors, barriers, and goals.
Social determinants of health, inadequate or inequitable access to healthcare and healthy food sources, insurance navigation, and other resource barriers also create roadblocks for patients who are otherwise interested in taking positive steps to improve their health. It is critical that the healthcare system better understand these practical barriers and consistently and systematically solve for them as part of a whole person treatment plan. This requires a fresh approach by those that deliver, administer, and pay for U.S. healthcare.
How healthcare providers can help patients build confidence to make healthier choices and change habits.
Patients need ongoing motivation and guidance from clinical care teams to help them evaluate the pros and cons of any proposed lifestyle or treatment changes. Additionally, patients need help exploring and overcoming practical barriers to personal change, answering a question that is often in the back of their mind but rarely explored by clinicians, “How can I do this?” Answering this involves identifying and solving for practical barriers, drawing on the help of people close to the patient, connecting the patient virtually with inspiring people who have successfully made similar changes, and helping them manage people in their lives who may be deterrents in their efforts to make healthy changes.
This personal focus needs to be a key part of the strategy aimed at improving our nation’s health. Care delivery for chronic conditions can be supported by evidence-based digital tools that help clinical teams stay connected with their patients between in-person visits and that empower patients to better self-manage their own health.
Clinicians need to help their patients see patterns in their typical day and diet, including their home environment and household habits around shopping, cooking meals, and daily activities. This helps patients become more aware of their attitudes, beliefs, strengths, and roadblocks to change. These insights should be included in the patient’s care plan and electronic health records to complement and enrich the traditional biomedical information and analytics.
The importance of long-term engagement.
Patients with chronic conditions are often on a life-long journey. To attain and sustain high engagement in treatment over time, clinicians must build trusting relationships by personalizing treatment plans and addressing all factors that contribute to whole person care.
Covid-19 has demonstrated the grave need for us to invest in chronic disease prevention and support by building stronger, deeper relationships with patients and families, and by focusing more on the environmental, social, and psychological factors that lead to chronic disease and impact long-term disease management. In a post-Covid-19 world, doctors can be supported by virtual teams of care management nurses, health coaches, health navigators, and use telehealth technologies to help patients with their daily challenge living with chronic conditions. We can pay for these new virtual clinical services from the savings we will get by reducing costly hospital and specialty care services we use today to treat chronic disease progression and medical complications.
If we want to be prepared for future viral pandemics, we must use this opportunity to stop, broaden our approach to chronic disease care, and collectively commit to helping people improve their health for the long haul.