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The term disease management has been part of the American health care vocabulary for nearly a decade, but how it is defined varies widely from one organization to the next. Your organization may have jumped on the disease management bandwagon in the early 90s without clearly defining the meaning or the scope of this managed care concept.
Disease management experts say it’s not too late to go back to square one, assess how you define and develop disease management initiatives, and correct any missteps, if necessary. Writing a concise working definition of disease management is the first step.
"Your definition of disease management should reflect the focus of your organization or business," notes John C. McDonald, RN, MS, CPHQ, administrator for general medicine and adult primary care at Vanderbilt University Medical Center in Nashville, TN. "An acute care facility may have one definition and a health plan may have another."
Many organizations focus on one service or product, such as case management or health education, when they define and implement disease management programs, but Vanderbilt uses a more comprehensive definition, adds Laurel Fuqua, RN, MSN, administrator of the Gastroin testinal Liver and Nutrition Care Center and director of disease management at Vanderbilt.
"We are trying to evolve all of our disease management programming around a more comprehensive definition. We define disease management as proactive intervention in the identification, management, and treatment of disease so as to organize services and products to address the total care of the patient and reduce costs," she says.
The key to Vanderbilt’s definition is a focus on "population management," adds McDonald. "Your focus has to be to keep your population as healthy as possible. If you are healthy, let’s work to keep you healthy. If you have a disease, let’s keep you as healthy as possible by decreasing complications associated with that disease."
Easy answers can be hard to find. "You can’t just say, We have a lot of asthmatics. Let’s manage asthma.’ What will you do with the asthmatic who is also diabetic?" asks Peggy Pardoe, RN, BSN, CCM, CPHQ, product development analyst for University Care, the managed care program at the University of Maryland Medical Center in Baltimore. "You have to understand the population you manage, not just the illness. Are your patients from a particular employer group? What does that employer do? Does the employer have specific population-based challenges? Are your patients white, middle-class suburbanites, or black and Hispanic inner-city residents, or a combination of both?"
Pardoe notes that it’s also important to understand the popular medical culture of your patients. "Have a clear understanding of the current best practices for diabetes. Then look at how your patients currently manage their diabetes. You have to understand what people are doing and why they are doing it so that you can address those issues in your disease management programs."
Another key part of an effective disease management programs is a "patient-centric" approach, says Sanjaya Kumar, MD, MSc, MPH, clinical project specialist with the Baton Rouge-based Louisi ana Health Care Review, a peer review organization contracted by the Health Care Financing Administration in Baltimore to improve quality of care for Medicare recipients in Louisiana. "The individual patient, not the disease process or cost containment, must be the focal point of all attention in terms of interventions that will be carried out in your disease management programs," he says.
"I see disease management as the provision of coordinated, comprehensive care via a multidisciplinary team across the continuum of care to achieve improvement in identified outcomes, such as functional status, quality of life, and medical costs," Kumar explains. "Disease management is no more than good clinical care across the continuum, if that is feasible under the current American health care system."
Whether you’re sitting down to refine your definition of disease management or starting from scratch, you can’t just write it down and then set it aside, Pardoe cautions. "You have to develop a definition that everyone in your organization agrees with. You can’t have renegades," she says. "You must have a party line. That party line is going to drive every disease management program you develop. It’s the philosophy that determines everything else you do."
Your definition of disease management forms the framework of the programs you create, she notes. "Does your organization think of disease management as pharmacy management? Do you look at disease management as health education? Do you separate disease management in your mind from case management? Or do you want to meet all the needs of the patient with a comprehensive approach that includes all of those services and more?"
Fuqua and McDonald suggest asking the following questions to assess your organization’s readiness to develop and manage its own disease management programs:
• What are your partnering capabilities and philosophies?
• How cost conscious are your employees?
• What are your quality efforts, and how effective are they?
• What data collection and monitoring capabilities do you have?
• What are your network relationships?
• What are your supplier relationships?
• What is your financial exposure or risk?
"These are key questions to answer to determine your readiness to take on the development of effective disease management," Fuqua says. "The answers to these questions will help you decide whether you should build your own programs or outsource. Every organization must answer those questions honestly. Most programs that fail do so because they haven’t given enough thought to those questions."
Kumar suggests adding a question to the list. "You must determine the boundaries or scope of your proposed disease management efforts. For example, do you want to intervene with all diabetics, or only those who need specific types of interventions, or only those with extremely high costs." (See p. 107 for tips on establishing intervention levels for your disease management programs.)
Homegrown disease management programs often are more valuable than vendor carve-outs because once you have built the infrastructure and developed your disease management philosophy and methodology, you can apply those elements to any future disease management efforts, say Kumar and Pardoe. However, if your organization’s infrastructure lacks the necessary elements to conduct effective disease management initiatives, you may consider turning to a vendor. (See story, p. 108, for components of an effective disease management program.)
Just remember: If it sounds too good to be true, it is, Kumar says. "If the vendor shows you a dramatic decrease in terms of admission rates for a given population within a short time span, then I can assure you that there’s some fallacy built into the data."
Also, don’t be swept away by a glossy bro chure, adds Pardoe. "Look at the fine print and ask lots of questions."
Pardoe and Kumar suggest asking vendors these questions:
• What studies were done?
• What scientific rigor was used in those studies?
• What was the study design methodology?
• What analytical methodology was used?
"If you don’t examine what you are being shown, you may be tempted to jump into a risky arrangement," Kumar cautions.
You may find a vendor can provide specialized services that your organization cannot. However, even when you use a vendor, you must stick to your own definition of disease management and your own strategic goals, Pardoe says. "You develop that definition. From the definition comes the strategic plan for each of your disease management initiatives. You stick to it. If you don’t, you will be at the whim of vendors and end up with a disjointed approach to your entire disease management effort."
The key to successful partnerships with vendors is to define the characteristics of your disease management initiatives clearly and make sure the vendor commits to your philosophy, she says.
"You must also establish exactly what you are purchasing and see if it fits that philosophy. Does the vendor offer the services your disease management strategy requires? For example, does the vendor provide case management or just health education? You want to be able to say, ’Whether we are planning an asthma program or a congestive heart failure program, these elements will always be the same.’ Vendors can reach a wide variety of patients. They can manage a wide variety of patients. What you have to weigh is whether they can manage your particular patients as well as you can internally," Pardoe explains.
"Do they provide personal education? Do they use case managers to deliver that education? Are those case managers certified? If their nurses aren’t certified, it tells me they have nurses but those nurses may not understand how to facilitate and coordinate services," she says.
The same holds true for outcomes. "If you choose a vendor, make sure that the vendor is willing and able to gather the outcomes you need, not the outcomes that make the vendor look good," she says.
Don’t be afraid to ask the vendor which software it uses to gather and analyze the data, Pardoe adds. "You may find that the software is commercially available and costs less to buy than the vendor’s services."