Building a Successful Disease Management Program

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Building a Successful Disease Management Program

• Maureen Padden MD MPH
• CDR MC USN
• Camp Lejeune Family Medicine Residency

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How many of you have previously been involved
with unsuccessful disease management efforts?

• Why were these efforts unsuccessful?

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Objectives

• Review the history of Disease Mgmt
• Differentiate carved-in and carved out models of
  disease management
• Examine the Wagner Chronic Care Model
• Review the Disease Management Road Map

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A Case for Disease Mgmt

• Diabetes
• Rampant in the US
• 1 in 7 healthcare dollars spent on DM
• Considerable morbidity and mortality
• 1992 3.5 of population responsible for 12 of
  healthcare expenditures.
• Imagine where we are today

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The Same Story True..

• Asthma
• Congestive Heart Failure
• Coronary Artery Disease
• Hypertension
• Any chronic disease self mgmt..

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We must move from a health care system that
manages disease already rampant.to one that
is founded in preventing disease to begin with
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Managing Chronic Disease

• PCM and Patient are only part of the process
• Multidisciplinary team best suited for job
• Teams can include
• Patient -Primary Care Manager
• Nurses -Pharmacists
• Others with clinical and behavioral skills
• Information specialists and epidemiologists
• Team ensures critical elements are met

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Earliest DM Program

• Run by Pharmaceutical companies
• Assisted managed care populations
• Care typically carved out
• Criticized for taking money from care in the name
  of profit
• Disrupted continuity of care with PCM

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Disease Management Today

• Largely left to primary care
• Appropriate specialty consultation
• Unstructured care in the community associated
  with
• Poor follow up
• Worse control and greater mortality
• CPG not sufficient...in house programs should
  assist providers

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Disease Management Models

• Two different approaches
• Carved in model
• Carved out model
• Choice of a model should be individualized
• Practice style of providers
• Needs / demands of patients
• Resources available at the MTF

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Carved-in Model

• Disease management is incorporated into Primary
  Care Team function
• Multidisciplinary team attends to various aspects
  of care
• Provider supported with tools to ensure that
  patients receive high quality care
• Right person delivers the right care in a
  familiar environment

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Carved-out Model

• Disease management is carved out from primary
  care team
• Separate disease management teams attend to
  that aspect of care
• Many HMOs favor such models
• Primary Care Team may lose contact
• Specialized team can focus on high risk disease
  management

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Carved-in versus Carved-out

• Which do you think is better?
• More importantly, which is a better fit for the
  culture of your MTF and patients?

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A Few Success Stories

• In Disease Management.

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Rossiter L, et al. The Impact of Disease
Management on Outcomes and Cost of Care A Study
of Low-Income Asthma Patients. Inquiry, 2000.
37p 188-202.

• Disease management of asthmatics in a Medicaid
  Population
• Findings
• 41 decrease in emergency room claims
• Emergency Room visits decreased by 6
• Dispensing of reliever drugs increased 25
• Cost effective analysis savings of 3 to 4 for
  every incremental dollar spent

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Rubin R, et al. Clinical and Economic Impact of
Implementing a Comprehensive Diabetes Management
Program in Managed Care. J Clin Endocrinol
Metab, 1998. 83(8) p 2635-42.

• Lewin Group studied Diabetes Netcare
• Carved out disease management program for 7
  managed care groups
• Economic savings 50 per patient / mo
• Hospital admissions decreased 18
• Bed days fell 21
• Patients more likely to get recommended
  preventive services

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Ginsberg B. Preliminary Results of a Disease
Management Program for Diabetes. JCOM, 1996.
3(4) p 45-51.

• Diabetes disease management programs at 5
  different facilities
• Reduced HbA1C 1.8 over 6-12 mos
• Pharmacoeconomic analysis
• lifetime cost savings of 27,000 per patient when
  compared against cost of acute and chronic
  complications
• Model suggested break even 6-7 years

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Wagner E, et al. Effect of Improved Glycemic
Control on Health Care Costs and Utilization.
JAMA 2001 285

• Group Health Cooperative, Seattle WA
• Large diabetic database
• Cohort of patients with sustained improvement gt
  1.0
• Associated health care savings 685 to 950 per
  patient per year within 2 years
• True despite this group having higher baseline
  HbA1C and more complications

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So why have many DM efforts failed?

• Over-reliance on Clinical Practice Guidelines
  (CPGs) as the cure-all
• Physician adherence often falls short
• Providers report time constraints at fault
• Deny the need for help, even in the face of
  evidence to the contrary
• Patient non-compliance is the default

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Patient Compliance

• The extent to which a persons behavior
  coincides with medical or health advice

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The problem with compliance...

• Gives no credence to the patients role
• Implies patients simply follow directions
• Adherence is a better term
• Characterizes patients as intelligent,
  independent
• Encourages active and voluntary role
• Patients help to define and pursue goals
• Adherence assumes patients to be equal partners

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Successful Disease Management

• Partnership between provider and patient
• Self-regulation changes patients behavior and
  improves health status
• Patient should be their own Primary Care Manager
  (PCM)
• Provider assists in establishing the best
  therapeutic plan for the individual patient
• The team adjuncts their support

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So How Do You Get There?
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Wagner Model

• Exemplifies how teams have an impact
• Framework for examining the disease management
  process
• Recognizes several areas of practice must be
  optimized for excellence
• Steps beyond the CPG quick fix
• Stresses practice redesign, patient education and
  expertise of providers

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Disease Management

• Best programs incorporate elements of Wagner
  model
• Certain aspects of care are delegated
• Elements
• Population management
• Clinical practice guideline
• Self-management support
• Intensive follow up

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Assumptions

• Simply providing a CPG wont change practice
• CPG is a small part of the big picture
• Major changes in clinical business processes must
  be undertaken
• Command unique planning must take place to ensure
  success
• Road Map developed to facilitate individualized
  process change

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Making the Roadmap Work For You

• Clear identification of disease champion and
  program coordinator
• Identify and maximize resources
• CPG guideline
• Patient and Provider Education Toolbox
• Collaborate with Performance Improvement
• Educate the health care team and patients

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Disease Mgmt Action Plan

• Utilize the MTF Road Map Action Plan to assess
  your requirements
• Leadership
• CPG and Metrics
• Disease Condition Management and Reengineering
• Program Deployment and Evaluation
• Education
• Marketing
• Identify and prioritize improvements

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Leadership

• Support exists from command
• Disease champion identified
• Program coordinator identified
• Key stakeholders and other members of team
  identified
• Command committed to evaluate outcomes of program

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CPG and Metrics

• Cohort to be managed identified
• Clear benefit for disease chosen
• CPG universally accepted
• Key metrics identified
• How will metrics be gathered?
• Plan to review metrics regularly
• Feedback to stakeholders on performance

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Re-engineering

• Project milestones mapped
• Clinical Business processes mapped
• Multidiscipline team involved
• Roles clear, standing orders in place
• Mechanism to contact patients not meeting
  benchmarks
• System in place to monitor patient compliance

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Deployment and Evaluation

• Timeline for deployment
• Mechanism for evaluation identified
• Tools for clinical business process
• Process in place to monitor clinician performance
  and feedback given
• Multidisciplinary team meets regularly to adjust
  and improve the program

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Education

• Education of providers on condition and
  expectations
• Baseline assessment of patients and families
• Staff continuing education
• Timely feedback to providers
• Patient self management incorporated into the
  program

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Marketing

• Baseline marketing plan
• Ongoing marketing plan
• External and internal customers

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Patient Self Management

• Overlooked aspect of chronic disease management
• Patients need support in between visits
• Stanford Chronic Disease Self Management Program
• Patients in the program managed overall health
  better than those not in the program
• Teaches patients coping skills
• The AA of chronic disease self management

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The Highly Trained PCM Team

• Highly trained PCM teams are powerful
• Reduce unnecessary and costly ER visits
• Limit specialty consultation to those cases
  needing their expertise
• Learn how to provide the care they have
  overlooked, deferred or referred in the past
• Improve health outcomes for their patients

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Many Ways to Improve Care

• Computerized central recall with prompting
• Cluster group visits with nurse educator
• Patient education/counseling by Pharmacists
• Periodic feedback to providers
• Providers will adjust and improve
• Information must be readily accessible at the
  point of care

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Bottom Line

• Program must be integrated into clinical
  processes in a way that works
• PCM centered
• Multidisciplinary team planning
• Program should be resource based
• Program should strive to create a more educated
  provider force

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Recommended Reading

• http//www.improvingchroniccare.org/change
• Wagner EH. Chronic disease management What will
  it take to improve care for chronic illness?
  Effective Clinical Practice. 199812-4.
• E.H. Wagner, B.T. Austin and M. Von Korff,
  "Improving outcomes in chronic illness," Managed
  Care Quarterly 4 (1996) (2) 12-25.
• M. Von Korff, J. Gruman, J.K. Schaefer, S.J.
  Curry and E.H. Wagner, "Collaborative management
  of chronic illness," Annals of Internal Medicine
  127 (1997) 1097-1102.

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Questions?