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The same is true at Christiana Care Health System in Newark, Delaware, which has given clinical leaders “financial room” to address chronic disease management, according to Roger Kerzner, MD, Clinical Director for Specialty Services for the Medical Group and Associate Service Line Leader for Primary Care and Community Medicine.

“The chief focus at Christiana Care is to continue to improve on the good work we are providing to our patients now that will be sustainable in the future and will benefit our long-term financial health,” he says.

Christiana Care is working to standardize care for hypertension, diabetes, substance abuse, COPD, and heart failure. The aim is to create a tight collaboration between primary and specialty care, which is bound to require culture change. “It’s a very different kind of care delivery model than physicians have been trained to provide,” Kerzner says, pointing to a nurse-run protocol currently being developed. Nurses would manage and adjust medication for hypertension patients without always needing to rely on a physician.

Christiana Care also wants to move chronic disease management into the community and offer “the same service in a different location,” helping to address social determinants of health and health inequity.

While remote monitoring has been successfully deployed at Christiana Care, the technology has not been fully implemented throughout the health system. “The first step is to create a system in which we can capture the full value of remote monitoring,” Kerzner says. “Once this is established, we can take advantage of this technology to improve chronic disease management.”