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Experts say you need these four components
If your organization is already committed to developing disease management programs, four essential components are necessary to implement them. If your internal infrastructure lacks any of these components, your disease management programs may be destined for failure:
1. Leadership. "You must have buy-in and support from the top down. Organizations who are truly doing disease management are creating a change in philosophy from fee-for-service, episodic care to comprehensive preventive care," says Laurel Fuqua, RN, MSN, administrator of the Gastrointestinal Liver and Nutrition Care Center and director of disease management at Vanderbilt University Medical Center in Nash ville, TN.
"If you can get your top people to buy into a disease management philosophy, then you can devel op programs that are successful in the long term and not just stop-gap measures. Disease management that meets the needs of patients also meets the needs of organizations," says Peggy Pardoe, RN, BSN, CCM, CPHQ, product development analyst for University Care, the managed care program at the University of Maryland Medi cal Center in Baltimore. "But you can’t save money without spending money. Disease management programs are costly. You must have support at the top."
You also must have your providers on board, cautions Sanjaya Kumar, MD, MSc, MPH, clinical project specialist with the Baton Rouge-based Louisiana 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. "Every time you develop a new disease management program, you must allow your providers a period of comment. Let your providers have input. They may add something you’ve overlooked. And, they are more likely to comply with your protocols."
2. Disease management mindset. "You must ask some key questions to help you understand where your organization stands right now, today, in terms of disease management," says Fuqua.
Questions you should answer include:
• What percentage of our daily efforts currently focus on disease prevention?
• What percentage of our services are available in outpatient and other alternative settings?
• To what extent have we carefully evaluated our current efforts at prevention and costs?
"If the answer to any or all of those questions is 0%, then you have a lot of groundwork to do before your disease management programs succeed," notes Fuqua.
3. Integrated case management. "Case management is the tool that assures that your standards of care for disease management are translated during the delivery of care," explains John C. McDonald, RN, MS, CPHQ, administrator for general medicine and adult primary care at Vanderbilt University Medical Center. "If your disease management protocol calls for certain lab tests to be performed at regular intervals, case management — whether performed by physicians, physician extenders, or nurses — is the tool you use to make sure those tests are performed on schedule."
"You always want case management to be part of your disease management process," agrees Pardoe. "Case managers have a way of establishing a relationship with patients and encouraging them to comply and participate in your programs. To gain compliance, you have to first gain the trust of your patients."
Pardoe recalls a patient who had been labeled "noncompliant" when she was working as a case manager for an asthma management program. After contacting the young woman, Pardoe found out she had been thrown out of her home, and her insurance card was left behind. "I contacted the clinic and begged them to see her even without her card. I looked into her legal options including her eligibility for Medicaid. She was living on the street, staying with friends. She could not have cared less that she wasn’t taking her maintenance steroids. Her life was a shambles. You can’t ignore those obstacles. That’s where case management comes in."
The easiest way for case managers to gain better patient compliance is to simply ask, "What do you need to make it easier for you to manage your disease?" Pardoe notes. "Ask the client to tell you the biggest problem they currently face. Or ask them to tell you the one thing that you could help them do better. You may have a parent with no particular interest in better asthma management for their child. However, that same parent may be missing too many days from work to care for the asthmatic child. Now, you have some common ground to get that parent’s buy-in. Tell them you think you know a way to make it possible for them to miss fewer days from work.
"When you develop your disease management programs, you can’t ignore the social, cultural, and spiritual aspects of your patients and how those aspects of their life affect their disease and their health," she says. "These are issues that case managers are well-suited to evaluate and address."
Most organizations have some type of case management, notes Kumar. "Find out what is currently being done for patients in your organization. You may find that many of the functions you want to include in your disease management programs, in terms of care received and follow-up after inpatient discharge, may already be taking place," he says. "You must look at your current case management process and see how you can coordinate that process with your disease management efforts." (See story, p. 110, for details on the prevalence of case management programs in the acute care setting and box, p. 111, for what qualifications hospitals look for in case managers. See also pp. 112-113 for discussion on what education case managers need to work effectively in today’s managed care environment.)
You may need to change some of the operations of the case management department to better support your disease management efforts, Kumar adds. "That’s when you realize again the importance of that top down buy-in for your disease management efforts."
4. Outcomes management capability. "You have to be able to gather data that shows you’ve had an impact on patient health." says McDonald. "That requires determining certain indicator points and tracking them. For example, we know that diabetics are less likely to develop chronic complications if their hemoglobin A1C is kept as close as possible 7%."
"You have to figure out which outcomes will help prove the effectiveness of your efforts and then determine what systems you need to measure them," says Pardoe. "You don’t have to start out with a sophisticated information system. You can start small and expand as your program expands."
One way to determine your data analysis capabilities is to write a request for proposal (RFP) to your own organization, Kumar says. "Too many times, the right hand doesn’t know what the left hand is doing in large organizations. Have your disease management team perform a needs assessment and then send out an RFP to see what is already available in your own organization. In addition to data analysis, you’re going to need analytical support.
"You need to understand and interpret the data once it’s gathered. Check to see if your organization has an academic affiliation you can tap into. Publicize your needs. There are hidden people within your organization. Don’t reinvent the wheel," he says.
If you are going to the time and expense of gathering data, make sure it’s data you can really use, he adds. "Don’t collect it if you’re not going to use it. Go back to your clinical goals and program parameters. Does the data you plan to gather support them?
"Many of the functions you’ll want to perform can be done with readily available business software, like Microsoft Excel. Don’t let the need for information systems hold back your disease management efforts," Kumar says.
It’s also important to determine a consistent approach to collecting outcomes data for each disease management initiative you develop, Pardoe says. "This will save time and establish a uniform way of reviewing outcomes while comparing the effectiveness of your various disease management programs."
(For more on what it takes to develop effective programs, see cover story.)