Jaykumar Menon


The history of health care reflects a number of approaches designed to improve the effectiveness and or efficacy of the delivery of services. Starting with acute care management and progressing over time through demand management concepts such as utilization review, pre-certification and case management, the health care delivery system has been a virtual laboratory for programs designed to improve the health of the population. Yet, study after study reveals that evidence-based standards of care for the treatment of chronic diseases are not being met. These and other studies also show that people with chronic diseases cost significantly more health dollars than do people without these diseases. Disease management, a treatment support concept predicated on the principle that healthier people cost less, is widely considered to be a meaningful solution to the health care quality, delivery and cost crisis associated with chronic disease.

While the volume of professional literature exploring the Disease Management concept is rapidly growing, there is still a scarcity of third party validated, peer-reviewed outcomes studies proving conclusively that Disease Management works. This situation is compounded by the fact that the Disease Management " industry " only came into being in 1993. Since then, it has grown in an unbridled and undisciplined fashion in the absence of a common definition, agreed upon minimal program components, and outcome measurement standards. As a result, programs being offered under the Disease Management banner span a gamut of services to health plans and other sponsoring organizations which include pharmaceutical market-share enhancement tactics, traditional utilization review activities, case management, demand management, primary disease management and comprehensive health care management for entire populations.

Unfortunately, industry consensus on these issues has been slow in coming. Further, what discussions have occurred have tended to overlook or ignore the critical leadership and input role that physicians must play if any Disease Management program is to be successful in fulfilling the basic conceptual premise.

The value of Disease Management to people with chronic diseases, their physicians and society as a whole, cannot be sacrificed to the immaturity of the industry. The simple truth is that Disease Management programs, properly designed and delivered, work. They can make people healthier and, as a result, they can save millions of dollars currently being spent. Disease Management represents an important advance in supporting the delivery of quality care to the patients.


Disease management represents a comprehensive, ongoing, and coordinated approach to achieving desired outcomes for a population of patients. These outcomes include improving patients' clinical condition, reducing unnecessary healthcare costs and improving patients' quality of life. To achieve these objectives requires rigorous, protocol-based, clinical management in conjunction with intensive patient education, coaching and monitoring --in short, a comprehensive system that incorporates the patient, physician and health plan into one system with one common goal.

Standards of Disease Management Programs

The disease management standards are organized into seven categories that encompass the minimal component set for effective disease management program. These are as follows:

1.ORGANIZATION : They address the administrative and programmatic requirements for disease management and includes-


· Medical Leadership

The medical leadership group includes representatives from Primary care physicians, Specialty physicians as appropriate to the disease management program and Health plan or sponsoring organization medical leadership.

Appropriate representatives of the health plan or sponsoring organization and the DMO support the medical leadership group. The selection of physicians to participate in the leadership group should include consideration of the following criteria- Experience with health care delivery within the local community, Board Certification, and active participating provider in the health plan's or sponsoring organization's network.

Written responsibilities for the medical leadership group are established. These include

Identification and review of provider issues, concerns, and recommendations, including all clinical practice guidelines, pertinent to the disease management program.

Recommendation, initiation, and assistance in the provision of professional education to other providers.

Review of the disease management clinical program and outcomes.

Attendance at meetings of the medical leadership group.

Oversight of the CQI plan/process.

The delivery of health care results from the interaction between a patient and his or her physician or other practitioner; the remainder of health care delivery system exists to support that relationship. Further, evidence suggests that management programs that provide meaningful medical leadership prove to be successful. Accordingly, medical leadership in the design, delivery, and review of disease management programs is essential.


·Coordination among Physicians and other practitioners


The Disease Management organization promotes coordination and communication among practitioners, primary care physicians and specialty physicians to provide care for all identified health care needs of each patient.

The primary care physicians or other practitioners manage a large percentage of the population with chronic diseases. It may be appropriate, at certain points, to refer to specialty physicians. When many physicians or other practitioners are involved with the care of a patient, they may not have all the important information necessary to manage the issues of health care at hand. The coordination of care and communication between and among practitioners is critical, since the continuity of care is necessary to attain the best possible clinical outcomes.

To achieve this, a list of specialty care physicians should be maintained. Important medical information should be shared between the practitioners, primary care physicians and specialty physicians. The consultation, referral and clinical practice guidelines specific to the disease must be established and approved by the Disease Management Organization and it should be distributed to all the network providers.


·Roles and Responsibilities of the DMO care team


The Disease Management Organization establishes responsibilities and promotes adherence to performance expectations for all staff members of the DMO.

All the staff members of the DMO are provided with a written job description. They are also provided with a formal orientation program that provides initial training. The DMO also provides a performance management program to assess, and improve as necessary, adherence to job responsibilities and expectations for its members. To maintain and improve competency, knowledge and/or skills for all staff members, the DMO coordinates continuing education.

The success of the DMO staff functioning depends on the depth of the initial orientation, understanding of roles and responsibilities, belief in the mission, and identification of opportunities for performance growth with appropriate education and training.


· Integration with Health plan/ sponsoring organization

The Disease Management Organization services are fully integrated with the health plan's or sponsoring organization's services.

Delivery of a comprehensive disease management program requires successful performance of a myriad of different activities, many of which the health plan or sponsoring organization may already be performing effectively. Whenever appropriate, the disease management program should not replicate such services. In order to assure all services are being performed, effective integration of processes between the health plan and sponsoring organization and the DMO and clear pathways of communication are critical to maximize the results of the program.

· Information System

The Disease Management Organization provides and maintains an Information System (IS) capable of supporting data design, collection, analysis, storage, retrieval, dissemination, and reporting to facilitate timely use of both clinical and financial data information.

The written IS processes are appropriately documented and maintained. Experienced and knowledgeable staff are available to support the IS for the disease management program. The DMO has a comprehensive strategy and program to assure the security and confidentiality of data and other information. It coordinates IS efforts with the health plan or sponsoring organization to ensure the delivery of meaningful, accurate, and timely data and information. The DMO assures that the IS promotes integration and timely sharing of information and physicians and other providers in order to provide a comprehensive picture of the patient's needs and health status. The DMO also assures that the IS tracks medical events, clinical interventions, and subsequent responses/outcomes.




The Disease Management Organization provides appropriate and timely communication with diagnosed patients, their physicians or responsible practitioners, the health plan or sponsoring organization, and other health care team members.

The goals of the program for the patients are consistent and are communicated to the practitioner, patient and the DMO care team. All the communication between the DMO and other members of the health care team is documented and maintained. The documentation reflects that communication among all health care team members is timely and appropriate to patient care needs. Feedback communication to physicians or practitioners is provided in a constructive and educational manner.

The challenge of effective communication is compounded in disease management due to the shift in focus from acute interventions to continuous management of the population's total health care needs. Effective disease management programs are those that facilitate clear and consistent communication flows with all involved parties, namely, the population being served, the health plan or sponsoring organization, and each member of the health care team.

Optimal clinical outcomes for a chronic disease population require the effective promoting and sustaining of behavior change for both the responsible practitioner and the patient. Sustained positive behavior change is greatly impacted by frequent and consistent messaging from members of the DMO care team.


·Patient care


The Disease Management Organization supports the coordination and integration of all the health care needs of all diagnosed patients of the population whether or not their needs are related to the defined diagnosis.

The DMO identifies and includes all patients within the chronic disease population being managed, regardless of overall health status. All newly identified health care needs of the chronic disease population are communicated by the DMO to the primary physician or practitioner.

The most successful disease management programs focus not only on the acute and chronic needs of the high-cost or high-risk population, but also the preventive needs of the remainder of the population. If the disease management program is going to be of continuing benefit over time rather than of short-term cost benefit only, attention to the whole population is imperative.

Further, because chronic disease impacts and, in turn is impacted by, all other health conditions, the successful disease management program focuses not only on the total population, but also on the patient's total health care needs.


·Patient stratification


The Disease Management Organization provides a formal stratification structure to assure appropriate interventions in accordance with each patient's health care needs.

Patient stratification is based on pre-determined clinical classification models, which includes clinical, behavioral, utilization, and cost components and patient stratification/re-stratification occurs as new clinical information becomes available. Each stratification level is linked to program interventions.

All patients are entitled to a minimum standard of care for most chronic disease programs. Some patients in the population will have progressed along the disease continuum and will require intensive and/or more frequent interventions. Programs that are built on the application of evidence-based standards and best practices reflect the ability of a DMO to apply appropriate resources at appropriate times as dictated by the needs of the population.




The Disease Management Organization has developed a pre-determined set of performance measures for the diagnosed population to evaluate program outcomes.

The DMO collects, analyzes and reports information/data consistent with those methodologies recommended by quality/regulatory organizations, and population based metrics defined by the DMO. Appropriate intervals for performance monitoring are set by the medical leadership group and reviewed in conjunction with the DMO and the health plan or sponsoring organization.

A critical component of a disease management program is the ability to determine, measure, and report performance toward program goals. Effectiveness of care delivered can then be evaluated in a variety of ways, including improvement in overall health status, satisfaction, and total health care costs.


·Complaint and Grievance Process


The Disease Management Organization ensures that a " Complaint/Grievance Resolution Process " is in place to address issues raised by patients or providers.

The Complaint/Grievance Process is written. The Complaint/Grievance Process is approved by the medical leadership group, health plan or sponsoring organization and DMO and is reviewed on at least a semi-annual basis. The patients and providers are informed of the existence of the Complaint/Grievance Process and their ability to access the same in accordance with quality/regulatory oversight organizations. The Complaint/Grievance Process is consistent and coordinated with that of the health plan or sponsoring organization.

Patient and provider satisfaction is essential to the success of the disease management program. Accordingly, the DMO considers the resolution of complaints to be a serious matter that calls for timely response. The Complaint/Grievance Process should be more substantive than a mere defense of current operations and services. Rather, they should provide opportunities to critically review program processes to determine if there are potential improvements to be made.

  1. PERSONNEL COMPONENTS: These address the staffing and Human Resources issues
associated with disease management.

The Disease Management Organization provides sufficient and appropriately educated and clinical and administrative staff with credentials to meet program requirements.

An adequate number of DMO staff is provided to accommodate the scope of services. Each member of the DMO staff has education/training appropriate to his/her role. Each professional member of the DMO staff is appropriately licensed and/or certified. Each member of the DMO staff performs responsibilities consistent with his/her education/training, licensure, certification, and within his or her state practice act. The DMO will assure that any subcontractor meets the appropriate standards with respect to education/training, licensure, certification, and responsibilities.

The success of the disease management program is highly dependent on and directly related to the DMO's ability to provide qualified, knowledgeable, and competent staff who will be able to practice within their professional practice guidelines.

required provision of support to physicians and other practitioners.

The Disease Management Organization provides education to physicians, other practitioners, and their support staff to facilitate successful management of the program population.

The physicians, other practitioners, and their support staff are educated by the DMO regarding current adopted clinical practice guidelines for the program population. It also provides education to physicians, other practitioners, and their support staff regarding tools and processes available for meeting the objectives of the DMO program.

It is essential that physicians, other practitioners, and their support staff be fully informed regarding current clinical practice guidelines and evidence-based treatment modalities.

The DMO also coordinates the provision of support resources to the physician and other practitioners in the management of the identified population.

The necessary resources for implementing the clinical practice guidelines should be agreed upon by the medical leadership group, health plan or the sponsoring organization and the DMO. Physicians and other practitioners are supported with assistance in complex case management when needed. Procedures are written and disseminated to support access to available resources. The DMO encourages physicians and other practitioners to make suggestions to improve the program.

Meeting the complex needs of patients with chronic diseases is a big medical care challenge. Therefore, the practitioner's knowledge of, and timely access to, available support resources have an impact on both quality and cost of health care.

The Disease Management Organization provides physicians and other practitioners data for their program patients.

The DMO communicates program outcomes to be reported. It also provides periodic outcome reports to the practitioners regarding their clinical practices with respect to peer groups and target references, which include evidence-based best practices.

There is evidence to suggest to that the provision of meaningful data and information can encourage physicians and other practitioners to adopt and or maintain best clinical practices; the provision of these data allows physicians and other practitioners to evaluate their own performances as compared to their peers.

4. OUTCOMES: These address metrics and measurement processes.

The DMO establishes written, predetermined clinical, satisfaction, and financial outcome metrics for evaluation of program performance.

The outcome metrics is established from clearly identified data sources. Established outcome targets are agreed upon and communicated by the medical leadership group, health plan or sponsoring organization, and the DMO. Clinical outcomes are based on evaluation of contemporary and generally accepted standards of care and best practices. The DMO conducts surveys at specified intervals regarding patient and responsible practitioner satisfaction with the disease management program. Outcome results are utilized to guide further continuous improvement in both patient care and program design. The methodology for data collection, analysis, and reporting of outcomes is specified and documented. Analyses are conducted as required to satisfy appropriate third-party reporting requirements.

The DMO also conducts clinical, satisfaction, and financial outcome analysis in a manner that addresses its program's impact on all patients with the disease.

The frequency and methodology for data collection, analysis, and reporting of outcomes is specified and documented. The base period for analysis and the time frame for documentation are defined prior to commencement of the DMO program. The denominator for all calculations should be the number of patients diagnosed with the disease, irrespective of whether or not those patients are participating in the DMO program. In financial analysis, the costs to be evaluated should include the total health care costs of the entire population of patients diagnosed with the disease, irrespective of whether or not those patients are participating in the DMO program.

Meaningful comparisons of disease management program effectiveness require a standardized methodology for analysis. While these mechanisms may evolve in sophistication over time, the standards outlined are designed to provide a uniform and, therefore, comparable basis for analysis for disease management programs.

5. CLINICAL PRACTICE GUIDELINES: They address adoption, dissemination, and


The Disease management Organization communicates comprehensive clinical practice guidelines (CPG) that reflect recognized standards of care and current best practices.

The medical leadership group adopts CPG reflecting the most current medical evidence available. The CPG and all subsequent updates are communicated to all physicians and other practitioners on a timely basis. The DMO provides a process to facilitate periodic review of CPG.

The foundation for an effective disease management program is the application of infrastructure, systems, and processes that support responsible practitioners and patients in adhering to evidence-based medical practices.

6.INTERACTION WITH PATIENTS: These address interactions with patients and their role in

self-management and appropriate use of resources.

The Disease Management Organization's interactions with patients are conducted in a professional, compassionate and supportive manner.

The DMO supports patients' rights to services and treatments consistent with adopted clinical practice guidelines. The organization ensures patient confidentiality and rights to use the complaint/grievance process and supports the resolution of complaints. It also ensures that communications with the patient are conducted in a courteous and respectful manner. The DMO also supports patient's right to decline participation in all or part of the disease management program and the patient/practitioner relationship and encourages patients to make suggestions to improve the program.

The DMO also coordinates the education program to assist the patient in self-management and effective use of available resources.

All the patients in the program are offered education, which is an ongoing process, and the information is disseminated. Educational materials approved by the medical leadership group are provided to the patients. These are contemporary and designed to empower them in self-management of their health and in appropriate utilization of resources.

The curriculum for patient education is available related to self-management and utilization of resources.


They address the Continuous Quality Improvement process, the quality improvement plan, measurement, and follow up for both clinical and financial aspects of disease management.

The CQI plan description defines scope, content, roles/responsibilities, and activities of the overall quality improvement process. The CQI plan defines roles and responsibilities of all the involved parties and the activities of the overall quality improvement process. The medical leadership group, the health plan or sponsoring organization and the DMO approve the plan. The medical leadership group provides the clinical oversight for the CQI plan development and implementation. The DMO and the health plan or other sponsoring organization provides the business oversight. Review of the CQI plan is documented on an annual basis and is modified as necessary by the medical leadership group, the health plan and/or sponsoring organization, and the DMO.

The DMO also provides a consistent measurement and assessment of clinical and business performance processes. It identifies the measurement and assessment of performance processes; and the identified measures used to assess performance are objective and quantifiable. The data collection and analysis process is identified and the data collected is analyzed to identify opportunities for improvement in quality of care and/or services provided.

The DMO also provides a mechanism for use of the CQI data analysis to improve clinical and/or business processes.

The organization defines the process of prioritization of opportunities for improvement. The DMO ensures interventions that address quality improvement opportunities are implemented and evaluated for effectiveness. It also ensures reporting of CQI efforts and results of effectiveness to the appropriate parties; and that the effectiveness of the current CQI efforts are fully reviewed when the next CQI plan is being prepared.

The CQI is an integrative process linking infrastructure, standards, and outcomes information, to assess and improve clinical and business processes, thus to improve overall quality of care and services provided.





"Cardiac Solutions." From http://www.ralinmed.com.

"Standards for Disease Management Programs." american healthways.