Disease Management (Position Paper)

Disease management is a set of activities aimed at improving the health and clinical outcomes of a population of patients, defined by all having a chronic medical illness. These activities are often organized through the use of technologies such as electronic health records 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 may be provided by a non-physician.

The American Academy of Family Physicians believes that population-based disease management is a core component of the New Model of Care, and is best performed within the patients’ medical home. Any disease management program or entity must involve the patient’s family physician to maximize continuity of care.

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 cost.

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-care techniques
Focus on improving the quality of care and patient outcomes
Clinical policies/best practices that extend across the entire continuum of care
Outpatient drug management
Clinical information systems with the capacity to identify, classify, and track defined patient populations
Informed support of physicians
Team-oriented, multidisciplinary approach
Feedback or continuous review of patient’s plan of care

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 as the patient’s care coordinator;
use an appropriate method to identify patient populations;
allow for voluntary patient enrollment into the DM program;
engage the patient in self-care 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 a continual loop of reporting and feedback between all parties involved in DM program;
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 family physicians’ authority to order ancillary support services or products as well as to refer patients to a specialist.

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 outcomes. A current limitation to effective DM may be the lack of evidence-based clinical policies upon which to base the programs. The AAFP will monitor and interact with organizations developing DM programs using Academy policy on "Patient Care, Concurrent," and AAFP definitions for "Consultation, Definition of," "Referral, Definition," "Transfer of Patient, Definition" and "Referral Guidelines, Definition." Also see “Care Management Policy - The New Model of Primary Care: Knowledge Bought Dearly." (1996) (2006)