Disease Management and Case Management

Disease Management and Case Management
Suzanne K. Powell
Hussein A. Tahan
LEARNING OBJECTIVES
Upon completion of this chapter, the reader will be able to:
  • Determine the similarities and differences between case management and disease management strategies.
  • Define important terms and concepts relative to disease management.
  • List the driving forces that lead to disease management programs.
  • Discuss important components to building a successful disease management program.
  • Describe factors that are important to the development, design, and implementation of a disease management program.
  • Identify the stages of the case management or disease management process.
IMPORTANT TERMS AND CONCEPTS
  • “At-Risk” Member
  • Best Practices
  • Component Management Model
  • Demand Management
  • Disease Management (DM) Model
  • Disease State Case Management (DSCM)
  • Disease State Management
  • Evidence-Based Guidelines/Health Care
  • Health Plan Employer Data and Information Set (HEDIS)
  • National Committee for Quality Assurance (NCQA)
  • Outcomes Measurement
  • Population Management
  • Practice Guidelines
  • Predictive Modeling
  • Quality Indicators (QI)
  • Report Card
  • Risk Screening
▪ INTRODUCTION
A. Case management (CM) as a component of disease management (DM) versus DM as a component of CM
B. CM—Use of an individual-based approach; DM—use of a populationbased approach. Both are multidisciplinary in nature and employ collaborative approaches to care delivery.
C. CM focuses on individual patients and operates across the continuum of care settings or delivery systems.
D. DM focuses on diseases within populations, and operates across the continuum of the disease.
E. DM emerged a little more than a decade ago in response to growing concern about the quality and cost of health care services for groups of individuals with common, chronic, and expensive health conditions such as diabetes, heart failure, and asthma.
F. DM programs target people with chronic illnesses for which long-term management, demand management, health education, health promotion and illness prevention, and close monitoring of symptoms can minimize or prevent acute exacerbations and complications (Huber, 2005).
G. DM programs were first implemented by managed care organizations as a service to their enrollees and employees and as an effort to reduce the expenses incurred in the care of employee with chronic conditions.
H. DM programs employ collaborative practice models of care. These models are multidisciplinary and consist of physicians, nurses, allied health professionals (such as dieticians), and support service providers.
I. According to the Disease Management Association of America (DMAA), DM is defined as “a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant” (DMAA, 2006). DM:
  • “Supports the physician or practitioner/patient relationship and plan of care;
  • Emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies; and
  • Evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health” (DMAA, 2006).
▪ KEY DEFINITIONS
A. Best practices—Practices that have been determined to produce the most favorable outcomes; these practices have been gleaned from comparative quality measurements and are thought of as ideal standards with national or international reputation.
B. Component management model—In this model, the “components” are the various providers that a patient may require along the continuum. Each component, separately and episodically, may strive for cost-effective, quality care.
C. Demand management—“The use of self-management and decision support systems to enable, educate, and encourage people to improve their health and make appropriate use of medical care” (Nash and Todd, 1997, p. 331). Demand management usually involves 24/7 telephonic nurse triage lines.
D. Disease management model—A holistic model of care provision in which all the components are (ideally) working toward the good of the population or of patients with a particular disease state that is mainly chronic and complex in nature, such as heart failure.
E. Disease state management and disease state case management—
  • DM uses a set of prospectively determined interventions with the intent of altering the course of the disease, improving clinical and financial outcomes, as well as quality of life, while reducing health care costs. The goal is preventing exacerbation of illness and reducing of the effects of co-morbidities, thereby avoiding or delaying the onset of acute episodes of illness (Powell, 2000b).
  • DM brings together outcomes research and clinical management of diseases to provide efficient care to patient populations in a continuous quality improvement environment. Furthermore, DM is a continuous process focused on efficiency and is applied to selected patient populations (Nash and Todd, 1997).
  • DM is a comprehensive, integrated approach to care and reimbursement based on a disease’s natural course, focusing on clinical and nonclinical interventions when and where they are most likely to have the greatest impact. Ideally, DM prevents exacerbation of a disease and use of expensive resources, making prevention and proactive CM two important areas of emphasis (Rieve, 1998).
  • Disease state case management (DSCM) is a population-based approach that identifies individuals with chronic diseases, assesses their health status, develops a program or plan of care, and collects data to evaluate the effectiveness of the process. DSCM proactively intervenes with treatment and education so that the individual with a chronic disease can maintain optimal function with the most cost-effective and outcome-effective health care expenditure. The goal of DSCM is to manage at-risk populations across the entire continuum of care (Levitt, Startz, and Higgins, 1998).
  • A system of coordinated health care interventions and communications for populations with conditions in which patients’ self-care efforts are significant. A DM program supports provider-patient relationship; emphasizes prevention of exacerbations using evidence-based protocols; and evaluates clinical, humanistic, and economic outcomes on an ongoing basis (Gorski, 2006).
F. Evidence-based guidelines, practice guidelines, practice parameters, and clinical practice guidelines—Defined by the Institute of Medicine as systematically developed statements to assist practitioner and patient decisions about appropriate healthcare for specific clinical circumstances.
G. Evidence-based health care—The purposeful and judicious use of best practices and evidence from systematic research findings in clinical practice.
H. Outcomes management—Seeks to produce desirable outcomes in a clinical setting, and is the application of outcomes research into practice. This involves assessment/measurement of outcomes at one point in time, monitoring and evaluation of same outcomes over time (longitudinal), interpretation of the data, and taking actions that focus on improving the outcomes.
I. Population management—A collaborative approach to identifying, mobilizing, and coordinating services to promote optimum community-based wellness within an identified population.
J. Predictive modeling:
  • A set of tools used to stratify a population according to its risk of nearly any outcome—ideally, patients are risk stratified to identify opportunities for intervention before the occurrence of adverse outcomes that result in increased medical costs (Meek, 2003).
  • Utilizing practice patterns to identify diagnostic groups or individuals at risk for adverse health events in order to proactively provide assistance with lifestyle changes to avoid, delay, or minimize the adverse health event.
K. Report cards, dashboards, and performance indicators—Reports that include a set of measures that can be used to rate providers, insurers, or health care plans according to their performance along several criteria. Common indicators include mortality rates, cost, rates of specific procedures, rates of hospitalization or emergency department visits for preventable diseases, and consumer satisfaction with care.
▪ DRIVING FORCES THAT LEAD TO DISEASE MANAGEMENT PROGRAMS
A. Fragmentation of care
  • In part due to the “component management model” of health care.
    • The “components” are the various providers that a patient may require along the continuum, with each component, separately and episodically, striving for cost-effective, quality care.
    • Usually does not support education or preventive elements through which hospitalizations and emergency care could be reduced
    • Studies have shown that optimizing any component of care separately from other components often generates higher system-wide costs (Nash and Todd, 1997).
  • A fragmented and chaotic environment or model of care results in medical errors and compromises patient care and organizational outcomes.
  • The disease management (DM) model has been used as an antidote to fragmentation of care.
B. Financial pressures
  • Cost pressures—Disease-specific health care spending
  • Risk sharing—Financial risk being transferred from the insurance company as the sole payer to the provider sector, thus sharing the risk
  • Growing concerns over the rising costs of health care services consumed by individuals with chronic illnesses
C. Quality improvement projects showing outcomes of care
  • Importance of quality improvement projects
    • Early projects often demonstrated poor quality of care.
    • Variations of practice patterns for the same disease state or procedure (e.g., prostate cancer or total hip replacement) are an area of concern among providers and health care payers.
  • Quality improvement projects assist in development of best-practice guidelines.
  • Best-practice clinical guidelines support strong DM programs. The use of evidence-based guidelines is an integral component of DM programs.
  • Process and outcomes measurement, evaluation, and management aspects of DM programs enhance quality improvement activities through identifying problems or undesired outcomes to be addressed and improved on.
D. Accreditation and certification programs that help ensure quality of care in DM programs:
  • The National Committee for Quality Assurance (NCQA)—NCQA’s DM accreditation and certification programs
  • Health Plan Employer Data and Information Set (HEDIS)
  • Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
  • Utilization Review and Accreditation Commission (URAC; also known as the American Accreditation Health Care Commission) DM accreditation program
E. Computer systems
  • Computer and information technology as a driving force in DM
    • Sophisticated software programs that assist the DM steps of population screening, patient identification, assessment, planning, condition management, and outcomes
    • Disease-specific decision trees are available and used by telephone triage nurses and demand management companies.
    • The crucial outcome measurement element that is responsible for continuous improvement in the management of disease would be impossible without sophisticated and integrated computer systems.
F. Informed consumers
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Jul 14, 2016 | Posted by in PEDIATRICS | Comments Off on Disease Management and Case Management

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