Don’t develop your next DM program without these guidelines
Don’t develop your next DM program without these guidelines
Here’s how to define DM and what you need to do it right
The term disease management (DM) has been part of the health care vocabulary in the United States for nearly a decade, but how it’s defined varies widely from one organization to the next. In fact, your organization may be one of many that jumped on the DM bandwagon in the early 1990s without clearly defining the meaning or the scope of this now-common managed care concept.
It’s not too late to go back to square one and assess how you now define and develop DM initiatives and correct any missteps, if necessary, say experts interviewed by Disease State Management.
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. "A pharmaceutical company may have one definition and an acute-care facility may have another."
Defining DM
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 Gastrointestinal Liver and Nutrition Care Center and director of disease management at Vanderbilt University Medical Center.
"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 to organize services and products to address the total care of the patient and reduce costs."
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."
"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?" says Peggy Pardoe, RN, CCM, CPHQ, product development analyst for University Care with 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?"
Also, find out where your patients live and which backgrounds they represent, Pardoe adds.
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 step in developing effective disease management programs is to use a "patient-centric" approach, argues 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. "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 notes.
"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," says Kumar. "Disease management is no more than good clinical care across the continuum, if that is feasible under the current American health care system."
Are you ready?
Whether you’re sitting down to rewrite or refine your definition of disease management or starting from scratch, you can’t just write your definition and then set it aside, cautions Pardoe. "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 develop, she notes. "Does your organization define 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 that you ask 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 current quality efforts and how effective are those efforts?
• What data collection and monitoring capabilities do you currently have?
• What are your network relationships?
• What are your supplier relationships?
• What is your current financial exposure or risk?
"These are key questions to answer to determine your readiness to take on the development of effective disease management," says Fuqua. "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 you add one more question to that list. "You must determine the boundaries or scope of your proposed disease management efforts," he explains. "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?"
Too good to be true?
Homegrown disease management programs are often more valuable than vendor carve-outs, because once you build the infrastructure and developed your DM 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 disease management vendor. (See related story, at right, for components of an effective disease management program.)
Just remember, if it sounds too good to be true, it is, warns Kumar. "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."
Don’t be swept away by a glossy brochure, adds Pardoe. "Look at the fine print, and ask lots of questions."
Pardoe and Kumar suggest you ask vendors the following 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 can’t. However, even when you use a vendor, you must stick to your own definition of disease management and your own strategic goals, notes Pardoe.
"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 you may end up with a disjointed approach to your entire disease management effort," she says.
The key to successful partnerships with vendors is to clearly define the characteristics of your DM initiatives and make sure that the vendor commits to your philosophy, says Pardoe. "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?"
The same holds true for outcomes. "If you chose a vendor, make sure that they are 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 they are using to gather and analyze their data, adds Pardoe. "You may find that the software is commercially available and costs less to buy than the vendor’s services," she notes.
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