Disease Management

Disease management is a set of activities aimed at improving the health and clinical outcomes of a population of patients, defined by a chronic medical illness. These activities are often facilitated by the use of an electronic health record, identification of "outliers" or "high utilizers" or disease registry programs. Disease management is proactive, aiming to provide appropriate support to enhance patient self-management activities. Through monitoring of recommended care for each patient, a good disease management program will reach out to patients with reminders, education, and other materials. In such a way, patient self-management is optimized in the interval between visits with the physician. In addition, those patients at highest risk for complications or other negative outcomes can be identified, and appropriate interventions offered. Family physicians serve as the optimal care coordinator to assist patients not only with clinical care and information, but in understanding and navigating the health care system.

Care coordination activities are the resonsibility of the entire care team and not only the primary care physician. Practice based care teams should engage communicaty resources as needed for the best outcomes for patients.

The American Academy of Family Physicians supports population-based disease management coordinated with the leadership of a primary care physician. Primary care centered disease management is essential for delivering the highest quality of care and is a core component of the patient-centered medical home (PCMH). Programs that bypass or fail to coordinate care with the PCMH are strongly discouraged.

Diseases or conditions which lend themselves to the disease state management approach include:

  • High cost per episode of care
  • High volume of provided care
  • Evidence of wide variations in care
  • Condition for which evidence-based medical guidelines exist that lead to improvements in outcomes for defined populations
  • Interest in reducing treatment variation and waste.

Successful disease management requires significant resources to develop and implement and may require some practices to collaborate with other entities to provide effective disease management. However, it is important for family physicians in all practice settings to familiarize themselves with disease management concepts, to review the cost and outcomes data, to recognize the potential for conflict of interest, and to manage care and advocate for their patients accordingly.

There are a number of components common to most effective disease management programs including:

  • Patient education and involvement in self management support
  • Focus on improving the quality of care and patient outcomes
  • Clinical policies/best practices that center in the primary care setting but extend across the entire continuum of care
  • Medication management and reconciliation across multiple points of care
  • Clinical information systems, such as registries, with the capacity to identify, classify, and track defined patient populations
  • Engagement and active participation of primary care physicians
  • Team-oriented, multidisciplinary approach
  • Regular review of patient’s care plan and planned care visits as needed

A comprehensive, well-planned and multidisciplinary approach to the management of health care is consistent with the traditions of family medicine. However, a team approach to patient care does not relieve the family physician of the ultimate responsibility for the care of his or her patients. Physicians should be able to deviate from disease management practice guidelines when judged appropriate without incurring sanctions or jeopardizing coverage for such services. Deviations need to be documented and can provide the basis for improvement in the guidelines.

The AAFP supports disease management programs that include the following:

  • Utilize the family physician and the practice care team as the patient’s care coordinator;
  • Use an appropriate method to identify patient populations;
  • Allow for voluntary patient enrollment into the disease management programs and activities;
  • Engage the patient in self management;
  • Emphasize the importance of prevention;
  • Support the physician-patient relationship;
  • Utilize evidence-based practice guidelines but allow for physician deviation when judged appropriate, without any negative financial and/or administrative impact to the physician and/or patient;
  • Utilize standardized performance measurements for processes and outcomes;
  • Promote collaboration between specialists and other providers of care with the family physician;
  • Perform ongoing evaluations of clinical, economic, and patient outcomes focusing on improving health status;
  • Maintain regular communication amount all parties involved in disease management;
  • Focus on providing appropriate and timely services;
  • Employ/utilize physicians overseeing the DM program who are licensed to practice medicine in the jurisdiction of the program’s location;
  • Support the family physician's responsibility to coordinate ancillary support services or products as well as to refer patients to a specialist as needed.

Disease management is an evolving concept which requires ongoing, accurate and verifiable data collection and peer reviewed publications which document cost effectiveness and improvements in patient outcomes. (1996) (2013 COD)