What are the design components of a disease management program?
There are four major components of disease management programs including claims data analysis, population selection and targeting, intervention, and quality measurement. All of these components are required to achieve successful program implementation and to meet cost and quality improvement goals.
- Claims Data Analysis
Claims data analyses are used to:
- Determine the most costly disease and/or combination of diseases, their prevalence and other population characteristics.
- Identify the top tier (e.g., 10 percent) of patients in these disease groups by cost and utilization
- Analyze the data by provider service category to determine medical cost components and utilization trends in the above groups
To begin the claims analysis process, patients with specific diseases and/or combinations of diseases should be identified from the claims database using definitions for major conditions such as congestive heart failure, asthma and other conditions.
Once patients are identified by disease they can be stratified by co-morbidities, cost and utilization, provider service category and any other criteria you wish to apply in the analysis.
Disease and disease groups are selected or targeted base on
- Noncompliance with national treatment guidelines,
- High potential for intervention and to improve clinical outcomes
- Evidence of inappropriate expenses/utilization which can be substantially reduced.
High resource utilizers can be identified through utilization data patterns (e.g., number of emergency room visits, hospitalizations, prescriptions, etc.) To further limit the population selection, specific patient subgroup categories can be included or excluded from intervention strategies. Those subgroup categories include for example Medicare dually eligible, long-term care, primary care case management, and managed care.
- Intervention
The intervention process is key in the implementation of DM programs and most frequently involves direct patient and physician contact. The provider/physician intervention goals include dissemination and education on treatment guidelines and monitoring parameters being measured as well as education on the feedback that will be provided throughout the process. Additionally physicians are informed about referral and patient education programs available and adjunct case management activities that will be provided.
Patient intervention goals often include administration of wellness and health surveys for baseline measures, risk assessment, disease and lifestyle education, direct patient outreach and interviews at specified intervals, patient feedback regarding performance and outcome goals, treatment compliance education, and other activities provided during case management.
- Quality Measurement
Successful DM programs always have a foundation of quality measurement in place. Programs need to be well planned with defined, realistic, and measurable goals. DM programs should measure cost of all components of care, quality of care, enrollee and physicians satisfaction and changes in heath and wellness of the enrollees.
Three specific elements must be measured to determine if a program is achieving quality improvement. Structure, performance (process) indicators, and outcomes should all be assessed and measured at regular intervals. Structural elements include examining how the structure of the delivery system functions such as the operational and administrative coordination activities performed by the DM vendor or providers with patients.
Performance Indicators - Effective DM programs will assess specific performance (process) indicators at defined intervals throughout the entire process and again terminally. These indicators include regular assessments and benchmarking that measure, track and compare performance to the pre-defined indicators. Performance (process) indicators measure the intermediate success of a specific action or intervention. For example, performance (process) indicators in a cardiovascular DM program would be measuring blood pressures and lipid levels of patients over time. Performance (process) measures can be easily and quickly tracked thus allowing DM programs to forecast the anticipated outcome based on the performance of specific intermediate measures.
Outcome Measures - Outcome measures differ from performance (process) indicators in that an outcome measure seeks to determine the end result of the action or intervention. For example, in a cardiovascular DM program outcome measures would include the incidence of strokes, heart attacks and death in the intervention patient group. Outcome measures take much longer to measure and are therefore more difficult and expensive to measure thus most DM programs rely on performance (process) measures to assess effectiveness.
Effective disease management has all the pieces of outcomes management, interdisciplinary teams, claims analysis and feedback, and medical treatment guidelines. The components of effective disease management can take many forms in terms of the tools used, the techniques, and the latest advances.
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