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Improve medical outcomes with “Disease Management Program”

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Disease management is the concept of reducing health care costs and improving quality of life for individuals with chronic conditions by preventing or minimizing the effects of the disease through integrated care. Disease management programs are designed to improve the health of persons with chronic conditions and reduce associated costs from avoidable complications by identifying and treating chronic conditions more quickly and more effectively, thus slowing the progression of those diseases.

Disease management is a system of coordinated heath care interventions and communications for defined patient populations with conditions where self-care efforts can be implemented. Disease management empowers individuals, working with other health care providers to manage their disease and prevent complications.

Disease management has emerged as a promising strategy for improving care for those individuals with chronic conditions. People with chronic conditions usually use more health care services, which often are not coordinated among providers, creating opportunities for overuse or underuse of medical care.

Disease management is a proactive, multidisciplinary, systematic approach to health care delivery that:
  • Includes all members with a chronic disease
  • Supports the provider-patient relationship and plan of care
  • Optimizes patient care through prevention and proactive interventions based on evidence-based guidelines
  • Incorporates patient self-management
  • Continuously evaluates health status
  • Measures outcomes
  • Strives to improve overall health and quality of life and lower cost of care
Components of disease management programs include:
  • Population identification processes :
    - Programs designed to target individuals with specific diseases
    - Chronic and costly conditions
  • Evidence-based practice guidelines
  • Collaborative practice involvement
    - Multidisciplinary teams that may include physicians, pharmacists, nurses, dieticians and psychologists
  • Risk identification and matching of interventions to need
  • Patient self-management education
    - Self management may include behavior modification, support groups and primary prevention Process and outcomes measurement and evaluation
    - A method for the measurement of outcomes may include heath care service use, expenditures and patient satisfaction
  • Tracking and monitoring system
    - Routine reporting and feedback loops that include patients and providers
    - Appropriate use of information technology

As a first step, a disease management program must identify the population group. Demographic characteristics, health care use and health care expenditures are generally reviewed to identify individuals who will benefit from a disease management program.

Programs target individuals with a specific disease that is chronic in nature and costly. Individuals with multiple conditions may also benefit from a disease management program.

Providers within disease management programs are critical to educating patients about their disease and how to better manage their conditions. Practice guidelines based on clinical evidence ensure consistency in treatment across the targeted population.

Chronic disorders commonly managed through disease management programs are:

  • Diabetes Mellitus
  • Congestive Heart Failure (CHF)
  • Chronic Obstructive Pulmonary Disease (COPD)
  • Coronary Artery Disease (CAD)
  • Asthma
  • Hypertension

Disease management generally entails using a multidisciplinary team of providers (for example, physicians, pharmacists, nurses, dieticians, psychologists) to assist individuals in managing their condition(s). Disease management programs are based on the concept that individuals who are educated about managing their disorder seek and receive better care.

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