How to identify, engage, and maintain continuity of care with these patients

Treating patients with chronic conditions was named one of the top challenges facing doctors in 2020 by Medical Economics. And that was before the COVID-19 pandemic struck. Managing the care of the 6 in 10 American adults who have a chronic disease entails regular visits with providers and also requires patients to adhere to their self-care and treatment plans between appointments. With COVID-19 causing delays and disruptions in health care, what is the best way to manage chronic disease patients now?

Identify and reach out to high-risk patients

Caring for patients with chronic conditions requiresa high-touch patient engagement strategy,” with regular check-ups, health coaching, and overall disease monitoring, according to PatientEngagementHIT.com. It’s especially crucial to keep up with these patients now, since underlying medical conditions increase the risk for severe COVID-19 illness.

Identify high-risk patients in your practice, such as those with behavioral health needs and those failing to show up for appointments or fill prescriptions.

Start by identifying your high-priority patients, suggests the Advisory Board. These include:

  • High-risk patients facing job loss, housing instability, and high rates of COVID-19 infection in their geographic area
  • Patients with behavioral health needs
  • Patients who aren’t showing up—e.g., cancelling appointments or failing to pick up prescriptions

Decide which form of care (phone consults, video visits, office visits, remote patient monitoring, etc.) is appropriate for patients based on their needs. As we’ve discussed on the blog before, appointments need not be either in-person or entirely remote—many doctors are finding success with a hybrid model that puts more emphasis on education and information-gathering before and after the visit, to maximize the in-person doctor-patient interaction.

Ask questions and educate patients on chronic disease management

“Patient engagement is one of the best tools in a provider’s arsenal in handling chronic disease management,” according to PatientEngagementHIT.com. When patients are knowledgeable about their health and fully engaged in their care, they are more likely to adhere to treatment plans and reach out to their doctors when they have questions. “These behaviors will ideally prevent an illness from getting worse and resulting in more costly and invasive interventions,” noted the article.

Eye doctors have seen an increase in chronic conditions such as dry eye during the pandemic. As more people have transitioned to remote work and distance learning, computer-induced dry eye and digital eye strain are on the rise. In this case, patient engagement looks like educating patients and prospective patients that their watery or burning eyes, blurred vision, and sensitivity to light have a cause as well as solutions.

Many people might not make the connection between their change in work environment and their symptoms, or realize that eye doctors can help. Sharing a video such as Healthy Daily Habits for Computer Users on your website or social media pages can be a great way to reach these people.

Asking patients questions about their lifestyle may uncover reasons why they are non-adherent with treatment protocols during COVID-19.

For existing patients, doctors should not only address symptoms and treat chronic conditions, but should also provide wellness care to help prevent chronic illnesses, according to Mark Wagar, president and CEO of Heritage Medical Systems, who told PatientEngagementHIT.com that “promoting wellness outside of the point of care should be the entire focus of health care.” For Wagar, this means asking patients detailed questions about their lifestyle.

This was how ophthalmologist Cynthia Matossian, M.D., discovered that many of her dry eye patients were not keeping up with their treatment regimens during the pandemic, she wrote in the Ophthalmology Times. “In talking with patients one on one, I’m discovering that they are doing a lot of things wrong, such as taking their omega-3 fatty acid supplements erratically or forgetting to take them with a meal.” Some patients were using their eye drops on an as-needed basis rather than twice daily as prescribed.

Patient education is the answer. People only absorb a fraction of what their doctors say during an in-person office exam or telemedicine visit, wrote Dr. Matossian, “so I’m realizing that we need to give instructions in many different formats.” 

Utilize technology and remote monitoring tools where appropriate

Technology makes it easier for both doctors and patients to stay connected and manage chronic conditions. Automated communication such as email and text reminders for appointment scheduling, patient care, and patient outreach as well as chatbots have proven to be effective and get high marks for patient satisfaction. Even before the pandemic, 81 percent of patients surveyed said they would be open to automated communication; that increased to 84 percent after the onset of COVID-19, according to a recent survey.

Technology such as automated patient communication, secure direct messaging, and remote monitoring can improve chronic disease management. 

Secure direct messaging through a patient portal is another tool for chronic disease management, according to another PatientEngagementHIT.com article. Patients may use secure messaging to ask their providers a question or seek health advice, and doctors can use it for “giving health coaching tips for patients, doing a quick check-in with a patient, or asking a patient about any irregular data gleaned from a remote monitoring device or wearable.”

An advancement in remote monitoring in eye care occurred in June, when Implandata Ophthalmic Products announced the launch of its web-based Eyemate IOP-Tracking Service for remote monitoring and management of glaucoma care. The Eyemate provides eye doctors with IOP measurements collected anytime under patients’ normal life conditions. The Eyemate system is available to patients in Germany, Switzerland, and the U.K., and has begun the FDA approval process in the U.S.

Currently, about half of all patients are using patient engagement technology to communicate with health care providers, according to research released in June 2020. To use electronic communication effectively and securely, doctors should discuss with patients the best ways to use the technology, what types of requests are appropriate to send electronically, and a standard timeframe in which the provider will respond to messages.

COVID-19 has presented new challenges in chronic disease management, for both doctors and patients. Utilizing a variety of patient engagement technologies ensures that these patients continue to benefit from regular, high-quality care from their trusted providers.


Many people with chronic diseases are in the older patient population, and they are especially vulnerable now. Find out how to reassure and re-engage them in care—read more now.