GENERATIONS – Journal of the American Society on Aging

feedback, in real time, to the person via the device or smartphone. This level of real-time interaction is promis- ing, but also creates new communication chal- lenges. Again, technology design processes must consider the filtering and collection of relevant information and close the loop on both the clini- cal data elements and interventions so that the managing primary care providers and special- ists can know which changes were made. Health systems must be careful not to add to fragmenta- tion as healthcare providers expand members of the care team to include those in remote settings (Chiauzzi et al., 2015). Social Determinants of Health: Closing the Gaps in Care Health plans and ACOs increasingly are tackling the social determinants of health, as awareness of their effects upon health outcomes and cost Remote monitoring of glucose levels and blood pressure has become commonplace. has increased. Often, condition-management programs are responding accordingly by screen- ing for social determinant barriers and partner- ing with CBOs to help close those gaps. Again, technology can be helpful in this work by collecting information on social determinants using novel methods (e.g., through app-based patient screens, by purchasing credit, census, or other data from data brokers) and by finding ways to meaningfully engage with CBOs beyond a simple referral. These engagements include sharing data elements, care plans, and other key pieces of information that help both parties to work with the person. Many organizations have included CBOs in patient-focused discussions, along with physicians and office staff, so that they can more easily identify new opportunities to help people and discuss care goals. One chal- lenge for ACOs and health plans is how they will

include CBOs in the financing of healthcare as CBOs play a larger role in caring for people hav- ing complex conditions. The most critical but often poorly studied strategy in any condition-management program is that which can affect behavior change and support engagement. In standard care environ- ments, individuals who are unwilling to change their behaviors around diet, exercise habits, or medication adherence often are labeled “non- compliant”—without any regard for the com- plexity of factors that influence such resistance to behavior change. Influencing behavior then requires first understanding the greater life context of each person. Assessments can begin to tell the person’s story, but to encourage and direct them toward a healthier path, a provider must also use relational skills, such as active lis- tening and motivational interviewing, to estab- lish a sense of trust. Using individualized education, as men- tioned previously, also can influence behavior. Giving a large volume of complicated informa- tion to a person who is not well-informed about their condition or who is not fully accepting of its potential risks, is not likely to be effective. The need for mass customization in engagement has pushed technology to adapt to various stages of the behavior-change model. Again, a combina- tion of technology and therapeutic relationships is helpful in establishing trust and motivating positive change. The Path Forward in a Value-Based World In a value-based world where health provider organizations’ sustainability depends upon achieving good outcomes and avoiding the complication of chronic disease, condition- management programs, if they are to succeed, must reinvent themselves from being primarily education programs to those that focus more deliberately on behavior change, the use of new data sources, and new clinical roles. Creative and effective examples exist across the country, notably the Centers for Medicare &

26 | Spring 2019

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