Today, nearly 129 million Americans live with at least one chronic condition. These long-term illnesses (such as diabetes, heart disease, and kidney disease) now account for a staggering 90% of the nation’s $4.5 trillion in annual healthcare spending. Unlike other care journeys, chronic conditions require continuous care, personalized monitoring, and long-term treatment strategies, placing a growing burden on already-stretched clinical teams.
With the number of patients diagnosed with chronic conditions expected to rise sharply over the next decade (driven in large part by an aging population), health systems must act now to equip their care teams with the tools and support they need.
In this article, we explore the key challenges of chronic care management and how AI-powered solutions like Commure Engage are helping providers meet those challenges head-on.
What Makes Chronic Care Management So Challenging?
Chronic care management (CCM) is designed to help patients with long-term conditions (such as diabetes, heart disease, cancer, and chronic kidney disease) stay on track with their health goals and improve their overall quality of life. But delivering consistent, effective chronic care at scale is no small feat, especially because these conditions are complex and require collaboration across multiple stakeholders. Providers face a range of structural, clinical, and social barriers, including:
Low patient engagement and adherence: Many patients struggle to follow treatment plans once they leave the clinic. Medication routines, lifestyle adjustments, and regular check-ins can feel overwhelming, especially for individuals who don’t fully understand their diagnosis or why these steps matter. At the same time, care teams spend two hours on administrative work for every hour of engagement with patients, making it nearly impossible for care teams to be available to respond in real-time whenever someone has a question or concern during their care journey.
Gaps in access and workforce capacity: Patients in rural or underserved areas often lack access to specialists, resources, or even basic healthcare services, in fact as of September 2024, 66.33% of Primary Care Health Professional Shortage Areas (HPSAs) were located in rural areas. Meanwhile, the healthcare workforce is increasingly stretched thin, leaving little time to proactively manage chronic conditions manually.
Fragmented care coordination: When providers across primary, specialty, and community care settings operate in silos, it can lead to communication breakdowns, duplicated work, and inconsistent care. Poorly managed care transitions in critical moments, such as hospital discharges, often result in confusion and missed follow-ups, putting patients at risk.
Outdated tools and disjointed data: Many care teams still rely on manual workflows, disconnected EHRs, and legacy systems that make it difficult to track patient progress, share information across teams, and manage long-term care plans effectively.
Social and behavioral health factors: Social determinants of health (SDOH) (including income level, housing stability, access to transportation, and health literacy) play a major role in a patient’s ability to manage their condition. Coexisting mental health challenges, such as depression or anxiety, can further complicate care and increase the need for support.
How AI Helps Relieve the Burden of Chronic Care Management
Chronic care management places a heavy burden on both patients and care teams. For patients, managing symptoms, treatment plans, and follow-ups outside the clinic can be confusing and isolating. For providers, fragmented systems and manual workflows make it hard to deliver consistent, coordinated care. AI can help on both fronts, giving patients timely, personalized support while reducing the administrative load on clinical staff.
Here’s how solutions like Commure Engage are helping:
1. Smarter Symptom and Side Effect Support
Managing chronic illness at home can be unpredictable. Patients often face flare-ups or medication side effects that cause concern and disrupt their care plans. Even when these issues are minor, they can lead to patient anxiety, a surge in messages to care teams who are already operating at capacity, and even unnecessary hospital visits.
Commure Engage helps alleviate this pressure. The platform uses AI and natural language processing (NLP) to respond to most symptom-related questions instantly, with answers tailored to each patient’s care journey. The guidance is pulled from a trusted, clinician-curated knowledge base, ensuring patients receive accurate, relevant information. This allows care teams to focus their time where it matters most, while patients stay informed, on course, and out of the hospital.
2. Better Data Collection and Clinical Visibility
Effective chronic care depends on data, but turning that data into meaningful insights has traditionally relied on time-consuming, manual work from clinicians.
Commure Engage helps streamline this process. The platform automatically collects patient data through SMS check-ins and connected monitoring devices, tracking changes in key indicators like blood pressure, blood glucose, and weight. All of this information appears in a clinician-facing dashboard integrated with the EHR, making trends easy to view and act on. Care teams get the insights they need, right when they need them, without the burden of manual data entry.
3. Stronger Support for Social Determinants of Health (SDOH)
Social factors like food insecurity, unreliable transportation, and limited health literacy can create major challenges for patients managing chronic conditions. These issues often occur outside the clinical setting, but the responsibility to address them frequently falls to care teams.
Commure Engage helps lighten that load. The platform checks in with patients through SMS-based conversations and automated assessments, using targeted questions to uncover common SDOH challenges like food insecurity, transportation issues, and limited health literacy. This gives care teams a clearer picture of the external factors affecting each patient’s ability to manage their condition. Based on those insights, the platform surfaces relevant resources such as nutrition support, ride services, or pharmacy access so patients can get help without adding more work for clinical staff.
4. Scalable Provider Communication and Care Coordination
Chronic conditions often require patients to interact with multiple specialists and providers. Managing these relationships can be overwhelming for patients and creates added complexity for care teams trying to coordinate treatment plans across roles.
Commure Engage helps simplify this process. The platform enables providers to collaborate in a shared communication thread, tagging one another to streamline coordination. It also uses AI to route patient concerns to the appropriate team members, helping ensure timely, personalized follow-up without adding friction to the care workflow.
The Future of Chronic Care Management Is AI-Enabled
Supporting patients with chronic conditions is a complex and resource-intensive task, but AI is making it more manageable. Platforms like Commure Engage are already transforming how health systems deliver chronic care by reducing manual workload, improving care coordination, and helping patients stay engaged between visits.
As AI continues to evolve, providers will be even better equipped to deliver proactive, personalized support at scale. The path to more effective chronic care is no longer a distant goal. It’s already taking shape.
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