Creating Solutions for Those with Chronic Health Factors

 The earnest question for health care professionals in today’s chaotic and increasingly time-pressured environment is, “Who is listening to the patient?”

Chronic disease management represents a vexing set of challenges for patients, families, physicians, health care professionals and health care delivery systems. The costs of providing care for patients with chronic conditions accounts for 90 percent of America’s annual health care expenditures.1   


THE STORY: Managing patients with chronic health conditions, particularly those with limited health literacy, is a critical competency that organizations must address to deliver high-quality, high-value care. Click here to read it.

ON THIS PAGE: Chad K. Brands, MD, CPE, SFHM, a member of the Physician Leadership Journal editorial board, comments on the article.

As clinicians recognize the enormous challenges patients face in coping with activity-limiting conditions, they can begin to channel this awareness into action steps for designing and redesigning health care delivery systems to more effectively evaluate and manage the acute and chronic conditions with which patients present from the broader social contexts of their communities. Well-informed physician-led teams and health care systems increasingly recognize the social determinants of health play a crucial role in the health of individuals and communities.2

Yet there are enormous challenges in pragmatically and effectively addressing the complex social determinants of health for patient populations with chronic conditions when these patients and their families seek the attention, respect and expertise of health care providers and teams in ambulatory, emergency and hospital-based settings. Communication with the patient and family, as well as information-sharing between interprofessional teams engaged in the patient’s care, remains paramount, but communication is often suboptimal in these settings including during transitions of care that represent time periods of high risk for adverse events and significant vulnerability for patients. 

Geskey has proposed a pragmatic framework for interviewing and interacting with patients with chronic diseases, particularly those with limited health literacy. This framework, set against the backdrop of social determinants of health, could be summarized as patient-centric and goal-oriented and could facilitate personalizing medicine for individual patients, particularly those whom clinicians might deem “nonadherent” to medical therapy.

Every patient is a teacher, and we as health care professionals must be students of each patient. The earnest question for health care professionals in today’s chaotic and increasingly time-pressured environment is, “Who is listening to the patient?”

Listening takes time, and active listening is easily usurped by the quest of looking for bits and bytes of information buried deep within the recesses of the electronic record. The computer screen or hand-held digital device often receives the doctor’s full attention instead of the patient. We need to remember that the prerequisite for empathy is listening. Listening becomes the first tangible evidence of actually caring for the patient who has a unique story, a story that is always set in the context of the larger social milieu.

Without identifying symptoms, signs and functional limitations and deciphering these manifestations in the realm of the patient’s world outside the health care facility, we will be unsuccessful in our attempts to improve quality of life or develop value-based systems of care delivery that improve health status outcomes for individuals and patient populations with chronic conditions.        

Geskey’s report highlights the concept of cognitive burden in the context of managing chronic conditions and the demands the symptoms and diseases place on patients with limited health literacy, including the escalating sets of challenges faced by geriatric patients with chronic conditions. Physicians recognize that chronic disease management is in serious need of clinical practice innovations, including technological advances and augmented decision-support modalities that readily can be implemented across hospitals and health systems.

He describes one hospital’s experience in implementing screening for LHL cholesterol on admission using the Newest Vital Sign, an instrument previously validated in medical literature. The hospital achieved a reduction in 30-day readmission rates for the selected patient populations with chronic obstructive pulmonary disease and heart failure that were screened on admission to the hospital.  

By focusing on a functional, goal-oriented approach directly related to activities that could be shaped into life goals by patients, the author notes that patients began to see the broader contexts of their conditions and potential solutions to improved health as well as functional status. As these insights accrue, health care providers and delivery systems will continue to enhance their understanding of the complex interplay between the social determinants of health and numerous contributors to well-being.     

The paper outlines a framework for health care providers who are interviewing patients and facilitating teams assisting them in setting and meeting realistic life goals, instead of resorting to the narrower approach in disease management that traditionally aims for a numerically defined laboratory target. The six-step model will remind hospitalists of “white boarding” goals with patients and families at the bedside to develop solutions and forward momentum for the day, week and hospital discharge.

Physicians as leaders must guide interprofessional teams to formulate probing questions that seek answers to understanding the social determinants of health, such as, “Who can assist the patient at this point?” and “How can these family members and care providers be brought into the hospital-based educational program now and better assist the patient at home given the identified social-environmental factors?”

These types of questions become formative in the professional development of interprofessional students, residents and fellows while learning just how difficult it is to effectively care for patients in the hospital where many of the complex social determinants are not readily apparent. It is this moment-by-moment bedside inquiry that enables physician-led teams to build better systems of care delivery to deploy the talent of a learning organization’s interprofessional teams to efficiently addresses and improve patients’ social determinants of health.      

Let’s all creatively consider how we can add value to patients’ lives, including those with limited health literacy, as we seek to develop and implement more effective systems-based practices in chronic disease management.   Then, we will truly be building a value-based health care system characterized by the delivery of evidence-based, highest-quality care for patients with chronic conditions. 

Chad K. Brands, MD, CPE, SFHM, is a member of the Physician Leadership Journal editorial board. He is an associate dean for graduate medical education at Liberty University in Lynchburg, Virginia.  


  1. Accessed Feb. 10, 2019.
  2. Accessed Feb. 10, 2019.

Topics: Journal

Improving Health for Limited-Literacy Patients
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