The cure for the traditional, fractured approach to treating polychronic conditions is bringing multi-specialty care to the patient—in their own home.
The disease burden of chronic conditions has been rising dramatically—a Milken Institute report estimated that 30.8 million people in the U.S. had three or more chronic diseases in 2015; projections suggest that approximately 83.4 million people in the U.S. will have three or more chronic diseases by 2030. These “polychronic” patients have complex care needs that strain resources and negatively impact quality of life.
Multiple factors drive these trends. Longer lifespans and lifestyle choices increase the chances of developing multiple chronic conditions; for example, the rise in obesity is linked to a higher risk of having several metabolic conditions, including cardiovascular disease, diabetes, and hypertension. This trend not only contributes to poor health outcomes it is also places financial strain on the industry, as 90% of the $5 trillion spent on U.S. healthcare annually involves people with chronic conditions.
Unfortunately, our healthcare system has not been adjusted to the changing demographics in the U.S. Diagnosing and treating a person’s health in a silo, organ by organ, is an expensive, ineffective, and antiquated way of delivering care. For positive outcomes, a comprehensive and personalized approach, simultaneously evaluating and treating the whole person and all chronic conditions, is required.
Historic, Systemic Issues
The current healthcare model misses the “big picture” by focusing on each chronic condition separately. There are three major problems with this historic approach:
- Patients quickly experience “specialist fatigue,” juggling appointments with multiple physicians and care plans that are not coordinated. This leads to conflicting instructions, multiple prescriptions that are not managed effectively, and confusion
- Social Determinants of Health (SDOH) barriers – such as lack of financial resources, food insecurity, and housing instability – are not considered when treating patients’ whole health. In fact, 30–55% of health outcomes entail SDOH factors.
- More time for the patient, but not more time with the patient. The average duration of a consultation with a primary care doctor is about 18 minutes – which is not sufficient to fully understand the patient. Not to mention the time spent scheduling, traveling to/from the appointment, waiting in the waiting room, or picking up prescriptions.
The solution to these challenges is holistic, in-home, patient-directed care.
A New Approach
Monogram Health’s patient-directed treatment model empowers patients to make their own health decisions by sending clinicians directly to their homes and giving them an integrated care plan personalized to their individual needs.
Monogram’s operations are physician-led and supported by local Advanced Practice Providers (APPs), registered nurses, as well as social workers, dieticians, and pharmacists. At the top of Monogram’s innovative model are multi-specialty physicians (i.e. cardiologists, nephrologists, pulmonologists, endocrinologists, palliative care and behavioral health) who have developed Monogram’s integrated clinical interventions, order sets, and protocols which are then carried out by the regional care team that goes into the patient’s home and performs behavioral, mental health, medical, and SDOH assessments used to create a personalized care plan that is continuously reevaluated. Monogram’s unique approach offers powerful benefits:
- Drive care in unique and powerful ways. The multispecialty-trained team can diagnose, treat, order tests, and prescribe medication through a specialty lens. Monogram’s innovative, integrated approach simultaneously evaluates and treats the whole person and all chronic conditions that are present.
- Forge a relationship with the patient, caregivers, and family members. The team offers support, education, and agency in a way that brief office visits cannot achieve. Family members and caregivers, in addition to the patient, can contact and instantly get connected with a Monogram clinician twenty-four hours a day, seven days a week.
- 360-degree view of the patient’s health. Being in the home provides a unique perspective for the clinician. Monogram clinicians can evaluate and review all medications, SDOH barriers, and conduct interdisciplinary assessments, such as behavioral and mental health—which cannot be effectively diagnosed on an intake form.
In fact, accessing mental health treatment can be burdensome, and 30% of Monogram’s patients have mental and behavioral health issues. That is why Monogram weaves these services into the fabric of all in-home visits, leveraging face-to-face interactions as well as tools like patient health questionnaires (i.e., PHQ-2 and PHQ-9) to deploy the right clinicians and treatments. Monogram has a chief psychiatrist as part of its multispecialty model who develops protocols and order sets to include this scope of services for patients.
Monogram’s model “bakes in” all aspects of a patient’s care that are often treated as “add-ons” or just not available elsewhere. For example, Monogram treats palliative care equitably and is embedded into every one of its clinical interventions and protocols. Similarly, Monogram’s pharmacy services are embedded into patients’ care plans; in which comprehensive medication reviews are given to all patients.
The Results
The number of conditions an average Monogram patient has is around 8. When taking a holistic approach to a person’s treatment and care, with all treatment options considered equitably, patients and partners alike experience:
- Better Outcomes. Monogram patients have 44% fewer hospital admissions and 52% fewer emergency room visits. Validating that their conditions are stable and managed.
- Affordability and Reduced Costs. Our partners have seen cost savings of $160M in 2024 and $375M in 2025.
- Better Patient Satisfaction and Experience. Monogram has a track record of improving NPS scores as well as a plan’s Star Ratings by +0.77 (on average).
The Future of Healthcare
In future articles, we will detail how Monogram expands the scope of care beyond traditional methods to treat a patient’s whole health, under one care plan, by employing an integrated team of clinicians and specialists across multiple disciplines:
- Cardiology. Integrated with other specialties, our in-home capabilities reduce stress and burden on patients’ hearts and lead to better cross disciplinary outcomes and a better quality of life.
- Pulmonology. Respiratory diseases like COPD and asthma intersect with and exacerbate other conditions. Our model focuses on early symptom relief through palliative principles and a holistic view to improve all aspects of a patient’s life.
- Endocrinology. Our in-home approach to endocrinology goes beyond treating diabetes and connects with all the other specialties to foster improved control and fewer complications.
- Nephrology. We do not just treat the symptoms of kidney disease but also the conditions that cause it.
- Palliative care. Palliative care is threaded through all the specialties; applying it early has a tremendous positive impact on a patient’s overall health.
Shifting away from fractured, siloed care that costs more and puts the burden on patients, Monogram is working to improve the patient experience and revolutionize the standard and delivery of treatment in the U.S.
The post Revolutionizing the Standard of Care and Patient Experience: A Holistic Approach to Chronic Conditions appeared first on Becker's Hospital Review | Healthcare News & Analysis.
Source: Read Original Article
