chronic disease management programme

Disease Management Programs: What Everyone must Know



What is Disease Management?     

Disease Management is the notion to reduce the health care costs and improving quality of life of individuals with chronic conditions by preventing or minimizing the effects of the disease through integrated care management.

disease management programs

chronic care management

Disease management programs are intended to improve the health of persons with chronic conditions and reduce associated costs from avoidable complications. These are usually done by identifying and treating chronic conditions more quickly and more effectively, thus slowing the progression of those diseases.

Read now:

Disease management is the coordination of health care interventions and communications for a defined patient population with conditions for which self-care efforts can be implemented. It empowers individuals, working with other health care providers to manage their disease and prevent complications.

Disease management is a promising strategy to improve care among those individuals with chronic conditions who usually use more health care services which often are not coordinated among providers, thus creating the opportunities for over usage or under usage of medical care.

Disease Management Program

Care coordination is the primary concerns of health care payors and providers. Individuals with chronic conditions have to ensure optimal health outcomes for which appropriate management and interventions required.

chronic disease management programme

It lays emphasis on the prevention of exacerbations and complications using evidence-based practice guidelines and patient empowerment strategies. It is done during the process of evaluating clinical, economic and humanistic outcomes which are essential to improve overall health and quality of life for patients.

The goal of this disease management is to encourage the patients to use medications properly, to understand and monitor their symptoms more effectively and possibly so that they can change behavior.

Comprehensive disease management programs can:

  1. Improve the safety and quality of care
  2. Improve access to care
  3. Improve patient self-management
  4. Improve financial cost containment
  5. Improve quality or patient satisfaction
  6. To provide health improvement programs on a population basis

Components of Disease Management

The following are the Disease Management components:

  • Identify the target populations
  • Which diseases should be addressed
  • How can people with those conditions be enrolled in a disease management program
  • Establish evidence-based practice guidelines for the conditions that will be managed
  • Build collaborative practice models
  • Educate the Patient
  • Measure outcomes
  • Feedback and reporting

Conditions Targeted for Disease Management

The following are the various conditions targeted for Disease Management:

  • Heart diseases including congestive heart failure, coronary heart disease, and hypertension
  • Lung diseases including chronic obstructive pulmonary disease (COPD)
  • Liver diseases
  • Diabetes
  • Psychiatric disorders such as clinical depression.
  • Alzheimer’s disease or other dementia
  • Cancer
  • Arthritis
  • Osteoporosis
  • Sleep apnea
  • Obesity
  • Asthma

What is the Role of the Pharmacist in Disease Management Programs?

Pharmacists are the important team members of the disease management process because as a member of the health care team, pharmacist provides education, as well as screening and medication monitoring services for the patients.

Pharmacists are usually involved in disease management programs in numerous ways but individual pharmacist involvement will vary according to each practice setting, Pharmacists:

  • Assist in the identification of individuals
  • Conduct monitoring for specific diseases, for example, diabetes, cholesterol, blood pressure
  • Provide patient education
  • Glucose monitoring
  • Peak flow monitoring
  • Assist with medication adherence
  • Provide direct patient care
  • Evaluate the outcomes of programs

As a member of a health care team, the pharmacist provides ongoing, comprehensive assessment of drug therapy and can share the results of that assessment with patients and other health care professionals.

How can I benefit from a DMP?

Chronic diseases are complex conditions and long-term regular treatment is required which should be tailored to suit the patient wherever possible. It is a way to better manage your disease in the long term and improve the success of your treatment. Taking part in a DMP offers some advantages, including the following:

  • People who participate in a DMP work with doctors who have specialized in treating their disease.
  • The doctors involved in a DMP are well-informed about the course of your treatment and will be able to give you more personalized attention during the regular appointments
  • All of the therapists and carers involved, both in inpatient and outpatient treatment, are to coordinate their interventions with one another.
  • Special training courses can make it easier for people with chronic diseases to actively take part in making well-informed decisions about their treatment and in finding ways to live with their disease as well as possible.
  • Another reason some people find a structured treatment plan helpful is that it reduces some of the time and effort involved in managing their disease. For example, they need not look for suitable specialists or hospitals themselves if they do not want to.

What is the aim of disease management programs?

  • To reduce the symptoms associated with a chronic disease
  • To keep them from getting worse
  • To prevent complications or accompanying diseases from developing
  • To help people cope with their disease
  • To show them ways of dealing with the demands of their treatment in everyday life
  • To improve the quality of life for program participants
  • To improve cooperation between the various specialists and institutions that provides care for a patient
  • To ensure that the individual treatment steps are well coordinated

How is the treatment provided in a disease management program?

After the diagnosis, medical consultations and examinations, the doctor will prepare an individual treatment plan based on the specifications of the Disease Management Program.

This plan includes medication and other treatments, training courses and regular check-ups, which may be carried out by other doctors or hospitals. For example, the DMP for diabetes involves regular eye tests in order to detect and treat possible eye damage early on.

The individual therapy steps and the outcomes of tests and treatments are documented to enable all those involved in the therapy to understand why certain decisions were made and certain measures are taken into consideration when planning for further treatment.

Patients who enroll for Disease Management Programs commit themselves to actively cooperate in their treatment by visiting a doctor every three or six months.

All of the participating health care providers such as doctors, hospitals, rehabilitation centers, nurses and trainers who commit themselves to fulfill certain quality requirements and follow the defined treatment plans.

Several things are done to assure quality in a DMP and this includes documenting and evaluating patient data regularly. The doctors get feedback reports on their treatment outcomes, which are also compared with the outcomes achieved by other doctor’s practices. Doctors can are also advised to attend training courses.

Though you would like to participate in a DMP, your family doctor does not take part, you may have to change doctors then.

How Disease Management Programs Save Money?

By implementing a disease management program,

  • Insurance companies and employers who provide health insurance can minimize costs and maintain a healthy workforce by proactively managing health-related risks
  • Wellness programs that offer incentives to exercise, eat well, quit smoking and take other basic steps toward good health can complement disease management programs
  • Reduce the need for expensive hospitalizations, procedures, and surgeries for chronic problems, because these are often the most expensive problems to treat
  • One way to mitigate the impact of continually increasing health care costs
  • Prove to be a financial positive and profitable tactic for the insurer

What do Practice Facilitators do on-site in the practice?

  • Help prepare practice for receiving health coaching services
  • Observe and analyze office processes and flow
  • Interview staff for points of frustration
  • Conduct clinic self-assessment
  • Abstract data from charts of chronic disease patients to look for gaps in care
  • Meet with the provider and key staff to determine goals and action plans
  • Facilitate system redesigns to close gaps and meet goals
  • Keep providers updated and receive direction from providers periodically
  • Assist with implementation of Care
  • Measures web-based disease registry
  • Teach quality improvement and process improvement to staff
  • Help practice develop a team approach to care
  • Follow up with practice after they leave to make sure systems are still working and address any problems

Chronic Disease Management

Chronic diseases are the long-term conditions which progress slowly over time and include conditions such as heart disease, diabetes, chronic kidney disease, asthma and chronic obstructive pulmonary disease (COPD), depression, and arthritis, among many others.

Chronic Disease Management (CDM) is an ongoing care and support for assisting the individuals impacted by a chronic health condition with the medical care, knowledge, skills, and resources they need to better manage on regular basis.

Chronic Disease Management include regular visits and support from your family physician, other primary care providers, community-based programs or referrals to the specialist programs and services.

Chronic disease management services

  • Physician consultation
  • Diabetes education
  • Nutrition advice from a qualified dietitian
  • Support, counselling, and information about community resources from a social worker
  • A personalized exercise program developed by a physiotherapist
  • An occupational therapist, who can assist you maintain your independence in daily activities

What includes Chronic Disease Management?

Good chronic disease management includes the following

  1. Proactive
  2. Team-based
  3. Well integrated with primary care (e.g. your family physician) and the broader community
  4. Coordinated across providers and points of care
  5. Easily accessible
  6. Has a focus on health promotion and well being
  7. Encourages the involvement of the individual

Diabetes Disease Management

Diabetes requires long-term, ongoing care in order to prevent the acute episodes and complications and improve member’s quality of life. The key components for controlling diabetes are as follows:

  • Practitioner education and adherence to established clinical practice guidelines
  • Member access to and completion of a diabetes management program
  • Availability of self-management resources
  • Access to member support network
  • Member-practitioner action plans

The diabetes disease management staff provides the education and assists the member and family in the following aspects of the Disease Management Process:

  • Importance of a member support network within and around the family of the member
  • Pharmacological therapy and routine medical appointments
  • Member education and attainment of self-management skills

Disease Management Programs – FAQs

Read here frequently asked questions about Disease Management Programs.

chronic disease management model

What Makes These Disease Management Programs So Great?

  • Reduction in company costs due to absenteeism
  • Reduced healthcare costs & expenditures
  • Increased quality of life at home and at work

What are the barriers of Disease Management Programs?

  • Workers finding time to participate – 39%;
  • Dispersed worker populations – 27%; and
  • Keeping the momentum going – 26%

How to calculate ROI of Disease Management Programs?

  • The use of health risk assessment (HRA)/screening condition/risk trends – 29%;
  • Factoring program expenses into their calculations – 29%; and
  • Total health plan cost trend lines – 21%

What are the various DMPs available for patients with chronic diseases?

  1. Asthma
  2. Chronic-obstructive pulmonary disease (COPD)
  3. Breast cancer
  4. Type 1 diabetes
  5. Type 2 diabetes
  6. Coronary artery disease (CAD)
  7. Chronic heart failure

What chronic condition management provides?

  • Phone-based help
  • Assistance coordinating your care
  • Help to monitor your illness
  • Dietary support to make sure you’re eating properly
  • Reminders to take medication and get medications refills
  • Recognize triggers and early symptoms
  • Identify risk factors, reduce and avoid them
  • Create and follow a treatment or management plan

What will be the patient interaction for Asthma management?

  1. Provide educational programs to patients about the disease,
  2. Conduct a periodic review of the patient’s inhaler technique,
  3. Perform ongoing monitoring of peak-flow function tests,
  4. Manage chronic medication use, including compliance assistance

What will be the patient interaction for Diabetes Management?

  1. Provide educational programs to patients about the disease,
  2. Regularly monitor both self-tested and laboratory tested blood glucose levels,
  3. Educate patients on how to use home blood glucose monitoring equipment,
  4. Monitor patient compliance with prescribed therapies and scheduled clinic and laboratory appointments
  5. Screen for drug/drug, drug/food, drug/lab, and drug/disease interactions and adverse drug reactions,
  6. Provide medication management and review

What will be the patient interaction for Hypertension & Cholesterol Management?

  1. Educate patients about these silent diseases
  2. Monitor compliance with medications, diet and exercise regimens,
  3. Screen for drug/drug, drug/food, drug/lab, and drug/disease interactions and adverse drug reactions,
  4. Perform periodic blood pressure checks,
  5. Perform periodic cholesterol level checks

What are the top chronic diseases?

The following are the top chronic diseases

  1. Alcohol-related health issues
  2. Diabetes
  3. Alzheimer’s disease
  4. Cancer
  5. Obesity
  6. Arthritis
  7. Asthma
  8. Stroke

What are the most common diseases?

  • Hepatitis B
  • Malaria
  • Hepatitis C
  • Dengue
  • Tuberculosis

What must be the goals for the Condition Management Program?

The following must be the goals for any condition management program:

  • Enhance subscriber self-management skills
  • Reduce intensity and frequency of disease-related symptoms
  • Enhance subscriber quality of life, satisfaction, and functional status
  • Improve subscriber adherence to the provider’s treatment plan
  • Improve communication among subscriber, provider, and health plan
  • Facilitate appropriate health care resource utilization
  • Reduce avoidable hospitalizations, emergency room visits, and associated costs related to the disease; and reduce work absenteeism and medical claim costs
  • Enhance subscriber closure of condition-specific gaps in care

What is the difference between case management and Disease Management?

  • Case management targets high-risk patients whereas Disease management targets patients who have one major diagnosis
  • Case management is not so flexible whereas Disease management is flexible

Hoping you read more about disease management plan and Disease Management Programs.

· · · · · · · · · · · · · · · · ·

Related Articles & Comments

Leave a Comment

Your email address will not be published. Required fields are marked *