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The answer is no, and they require different care
If you keep the "patient" at the center of all your disease management programs, you soon realize that not all interventions are appropriate for every patient in your target group, says Sanjaya Kumar, MD, MSc, MPH, clinical project specialist for Louisiana Health Care Review, a peer review organization in Baton Rouge. (For more advice on developing disease management programs, see p. 105.)
"Your program should define what action is taken depending on the degree of progression of disease," he explains. "You must select some logical pattern of interventions based on identified characteristics within the group you’ve captured."
Using diabetes as an example, not all diabetics will have the same degree of knowledge about diabetes management, Kumar says. "One preliminary step you should take is to capture basic information about your population through patient records and billing data. Which diabetics have been hospitalized? Which have been in the emergency room? Which have experienced foot problems?"
After gathering these preliminary data, you should stratify your population into action groups, he notes. "The interventions should be common to all the diabetics in your population. What will vary is the intensity, or frequency, of the interventions."
Assume, he says, that you have a population of 100 diabetics. You decide to place them into three intervention categories. The first group consists of stable diabetics requiring minimal intervention. The second group consists of mildly unstable diabetics requiring a slightly more intense level of intervention. The third group consists of uncontrolled diabetics requiring the highest level of intervention.
"You may have five or six interventions included in your diabetes management program," Kumar says. "The first might be telephonic coordination of services and follow-up by nurse case managers. The second intervention might be education regarding their disease — nutrition and exercise guidelines. What varies is the frequency of the phone calls from the case manager and the number of health education interventions. You may schedule calls once every three months for the stable group and once every two weeks for the uncontrolled group."
Yet you also should remember that patients will not necessarily remain in the same intervention group, he says, explaining that your program should include clinical guidelines for reevaluating patients to check their status. Do you, for instance, test hemoglobin every three months for stable patients or every six months?
"People are not automobiles. Your population is not going to be static. It’s going to be dynamic," Kumar explains. "Those diabetics who were stable on enrollment may have a death in the family which causes them to neglect themselves and moves them into the uncontrolled category. You may have to increase the frequency of your interventions until they stabilize and then move them back to their original category."