Call it the new normal: Across generations and demographics, more families are coping with chronic disease in their daily life.

The U.S. Centers for Disease Control and Prevention (CDC) says one in four Americans has multiple chronic conditions, and that number jumps to one in three over the age of 65.

Patients with multiple chronic conditions are more likely to need hospitalization and costly medical attention. About 71 percent of total health care spending is for care of patients with more than one chronic condition, the CDC says.

But the current health care system is organized to offer care on a “disease-by-disease basis,” says an article from the U.S. Department of Health and Human Services (HHS). “So when individuals see a number of specialists, the opportunity for confusion exists … Care coordination is often the missing link.”

To meet this challenge, health care systems and industry are increasingly moving toward population health management, an approach that focuses on continuous health and coordinated care for at-risk populations and that relies on interoperable technology and meaningful data to enable improved outcomes, lower costs and a better, more complete patient profile. A large part of population health management is collecting data from various sources and using it to educate doctors and patients alike.

But how does that work in reality? Take the “Curran” family, for example (pseudonyms are used to protect the family’s privacy).

Amanda, 28, a homemaker, sees her doctor every month for medication to control her ADD, asthma and acid reflux. Her husband, Joe, 38, a plumber, has high blood pressure and persistent back pain that often sends him to the emergency room or the doctor for relief. Her mother, 52, takes anti-depressants and medication for chronic vertigo, and her father, 59, takes a handful of pills three times a day for diverticulitis, COPD and the pain of spinal cord nerve damage, the result of a work-related accident. Other relatives have diabetes, heart disease and arthritis. Her daughter Sarah is healthy - so far - but, Amanda says, with her family’s history, “I just worry she’s going to get all this.”

The presence of so many chronic illnesses in one family is not unusual, writes Jeroen Tas, CEO, Connected Care and Health Informatics at Royal Philips, in an blog, noting his own family is living with multiple health issues.

More people can control and live with medical conditions that might have previously been fatal, because of advances in diagnoses, clinical care and new medications. The aging baby boomer generation and the prevalence of obesity, inactivity and smoking are adding to the growing burden of chronic disease. “A glance at global disease statistics indicates to even the untrained eye that we are swiftly approaching an acute situation,” Tas writes.

Implementing effective population health management could help alleviate these acute problems.

The concept of population health is not new, says Jennifer Covich Bordenick, CEO of the eHealth Initiative, a nonprofit that researches and advocates for improved safety and care through information and technology. But only in the last five to seven years has the automation of health care data, with electronic health records, pharmacy programs and wearable monitors, been more widely available, generating huge volumes of information.

“Now we have a treasure chest of information,” Covich Bordenick says. “One of the biggest challenges is corralling that data, interpreting the data and coming up with actionable information, data you can actually do something with.”

THE CHALLENGES OF CHANGING THE SYSTEM

The goal is to provide coordinated, continuous care of patients both inside the hospital and beyond, and that’s the biggest management challenge cited in a survey of healthcare leadership by HIMSS Analytics for Philips Healthcare. A majority of health systems have launched population health management programs, the survey found, investing in technology that connects data and drives measurable clinical improvements. But taking those programs beyond hospital walls, managing continuous care in a way that engages real patients, may take a sea change involving large-scale cultural and operational shifts.

According to Tas, within the health care system, it will mean new ways of working in multidisciplinary teams and providing care remotely, and a change in reimbursement policies from fee-for-service to payment for preventive care and health promotion. That will take the combined efforts of industry, government, health systems and academia to embrace innovation and sharing of best practices.

Going beyond those combined efforts, Robert Groves, MD, vice president of health management for Phoenix-based Banner Health, says within health care systems a “central nervous system” is needed to weave data, physicians and patients together to save lives and reduce costs.

Over the past three years, Philips has been powering a telehealth program with Banner Health in Arizona, providing tablet devices to patients with multiple chronic conditions, allowing them to connect remotely with their health care teams. After the first six months of activating the program, Banner reported a 45 percent reduction in hospitalizations, a 32 percent reduction in acute and long-term care costs, and a 27 percent reduction in the cost of care.

“Telehealth is increasingly viewed as a cost-effective method to deliver patient care and expand access,” says an American Hospital Association Issues Brief published in April, 2016. “The growing use of telehealth reflects larger health care trends that place the patient’s care and experience at the center of treatment decisions.”

THE NEXT STEP: GETTING PATIENTS INVOLVED

Perhaps the biggest hurdle, says eHealth Initiative’s Covich Bordenick, will be getting patients, like the Curran family, involved in their own health care.

“Population health is about ordinary people, mothers, fathers, kids, who have chronic health conditions that need to be managed,” she says. “Patients are being diagnosed more often now, so while we’ve always had these problems, there weren’t always plans of action. How do we manage these ordinary patients in their homes on a regular basis in an unobtrusive way that allows them to live their lives? And who is responsible for overseeing it all?” Patients may have little or no contact with a hospital and sporadic interaction with a primary care physician or a variety of specialists. “Is it the government’s responsibility? The health system’s responsibility? The question is tricky,” Covich Bordenick says, “but the answer we come back to is that the consumer needs to be engaged. People need to be responsible for their own care.”

A good population health program identifies people who need help, puts interventions in place, monitors progress and keeps all parties informed. Programs aimed at getting people to exercise, lose weight, stop smoking or change other adverse behaviors often fail because they approach patients from the wrong direction. “It’s not something you can do to a patient,” she says. “It’s something the patient has to do. You need a program that engages and encourages patients to be engaged in their health and gives them incentives to take care of themselves,” she says. “A lot of it is understanding what works, what incentives work, what gets patients to change their behavior.”

The tools are there, she says, but that’s just a start. “Everybody has a smartphone. We can definitely get information to the patient, and then from patient to doctor,” she says. “But it’s acting on that information – what does the patient do with that information, what does the doctor do – and that’s the turning point. That’s the critical piece in population health: What happens next?”