Disease Management: Proactive vs. Reactive? Reengineering

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Disease ManagementProactive vs.
Reactive?Reengineering for success

• Maureen O Padden MD MPH
• CDR MC USN (FS)

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The Reality of Healthcare Today We must move
from a health care system that manages already
rampant disease.to one that is founded in
preventing disease to begin with
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How many of you are aware of Business Planning?

• Have you been involved?

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Setting the Stage

• BUMED Business Plan mandates implementation of
  disease management
• Diabetes performance metrics identified
• Modest expectations HEDIS HbA1C, LDL
• MTF PerformanceWhole Goals
• Population Health Navigator (PHN) the accepted
  information source
• Diabetes Action Team (DAT) Accepted the DOD VHA
  Diabetes CPG Toolkit

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False Assumptions

• Simply providing a CPG changes practice
• MTFs have clinic processes that optimize disease
  management
• There is no more work to be done in disease
  management at our facilities
• It is easy to implement change in our MTFs

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Wagner Model

• Exemplifies how teams can have an impact
• Framework for examining the disease management
  process
• Recognizes that several areas of clinical
  practice must be optimized for excellence
• Steps beyond the CPG quick fix
• Stresses practice redesign, patient education and
  expertise of providers

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Disease Management

• Best programs incorporate elements of Wagner
  model
• Certain aspects of care are delegated
• Elements
• Population management
• Clinical practice guideline
• Self-management support
• Intensive follow up

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BUMED MTF Road Map for Disease Management

• Based on the Wagner Model
• Assists teams to consider how they might redesign
  their practices to optimize disease management
• Requires multidisciplinary approach from various
  stakeholders to be most effective
• Now used by the MedIG team as well

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Clinician Basics

• Familiarize providers and team with CPG, BUMED
  metrics and sources of data
• Carefully define team member roles as clinical
  business process is redefined
• Ensure providers have the knowledge necessary to
  execute high quality care
• Timely and regular feedback to providers
  regarding their performance is paramount

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Disease Management Models

• Two different approaches
• Carved in model
• Carved out model
• Choice of a model should be individualized
• Practice style of providers
• Needs / demands of patients
• Resources available at the MTF

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Carved-in Model

• Disease management is incorporated into Primary
  Care Team function
• Multidisciplinary team attends to various aspects
  of care
• Provider is supported with tools to ensure that
  patients receive high quality care
• Right person delivers the right care in a
  familiar environment

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Carved-out Model

• Disease management is carved out from primary
  care team
• Separate disease management teams attend to
  that aspect of care
• Many HMOs have favored such models
• Primary Care Team must maintain contact
• Specialized team can focus on high risk disease
  management

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Carved-in versus Carved-out

• Which do you think is better?
• The answer lies in which is a better fit for the
  culture of your MTF and patient population.

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Patient Compliance

• The extent to which a persons behavior
  coincides with medical or health advice

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The problem with compliance...

• Gives no credence to the patients role
• Implies patients simply follow directions
• Adherence is a better term
• Characterizes patients as intelligent,
  independent
• Encourages active and voluntary role
• Patients help to define and pursue goals
• Adherence assumes patients to be equal partners

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Successful Disease Management

• Partnership between provider and patient
• Self-regulation changes patients behavior and
  improves health status
• Patient should be their own Primary Care Manager
  (PCM)
• Provider assists in establishing the best
  therapeutic plan for the individual patient
• The team adjuncts their support

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The Highly Trained PCM Team

• Highly trained PCM teams are powerful
• Reduce unnecessary and costly ER visits
• Limit specialty consultation to those cases
  needing their expertise
• Learn how to provide the care they have
  overlooked, deferred or referred in the past
• Improve health outcomes for their patients
• Seek information from important liaisons such as
  Tricare to continually improve care

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Disease Management

• Chronic Diseases such as Diabetes consume a large
  fraction of healthcare
• Early management and prevention of costly
  complications is ideal
• How do you manage patients with chronic diseases
  such as Diabetes, Asthma and Heart Disease?
• Are you proactive or reactive?

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If You Could Set Up the Ideal Disease Management
ProcessWhat Would It Look Like?

• A Case Study in Diabetes

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Regular visits

• Prevention of complications of chronic disease
  requires regular visits
• How do patients access care in your facility? Do
  you wait for them to call for an appointment on
  their own?
• Consider developing a mechanism to contact
  patients with high cost medical issues to ensure
  they come in regularly

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Clerk Calls Patient Due Care
Hi Mrs. Smith. This is Jim from Family Medicine
Clinic. It has been three months since your
last diabetes check up. Can I make an
appointment for you to see your doctor for follow
up?
Jim has standing orders to call patients in their
Diabetes registry who have not been in for care
in the last 3 months. He calls patients at home
to remind them and makes an appointment that is
convenient for the patient.
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Clerk has standing orders
Great. I have you scheduled for Monday December
12th at 900 am. I am also going to order some
blood work for the doctor. Can you come in a
week before your visit and have that drawn? If
you havent had your eyes checked yet this year
or if you want to see nutrition, I can place
consults for you at this time.
James correctly notes that the appointment Is for
diabetes follow up so the team is aware of the
reason for the visit. He enters labs in CHCS
under the assigned provider.
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Patient arrives for appointment

• Checks in at front desk
• Insurance and address verified in computer system
• Team member sees that the patients appointment
  is for diabetes follow up
• Clerk has standing orders Patients following up
  for diabetes complete standard questionnaires

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Corpsman or Nursing Staff

• Places patient in exam room
• Takes vital signs
• Reviews medication list
• Inquires regarding tobacco and alcohol use /
  desire to quit
• Patient removes shoes. Nurses are trained to do
  the foot exam
• Inquires regarding Influenza, Pneumovacc, daily
  aspirin and other prevention strategies
• Takes an initial history to see how the patient
  has been doing

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Time with the Provider

• Reviews already resulted labs
• Focuses discussion on achieving
• Glycemic control
• Lipid control
• Blood pressure control
• Use of daily aspirin
• Recommends course of action / change in
  medications to achieve these goals
• Addresses primary care concerns
• The other team members contributions allow him to
  focus on those areas that require his expertise

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No missed opportunities

• Nurse returns prior to patient departure and
  provides immunization if the patient is due for
• Pneumovax
• Influenza
• Tetanus

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Check Out With Clerk
Hi Mrs. Smith. Nice to see you again. Dr Jones
wants to see you next month so I am making you an
appointment. If you need to change it, just call
me. I reentered your eye consult for you. Dr
Jones would also like you to go by the lab and
pharmacy today.

• Patient directed to check out with clerk before
  leaving the clinic
• Follow up appointment made for next visit in 1-3
  months
• Any needed consults per provider are entered
• Patient directed to lab if additional blood work
  is needed

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Clinic Appointment Cards(Front)
Happy Hospital Family Medicine Clinic (301)-555-12
12 Next appt _____________________20__ Circle
one Mon Tue Wed Thu Fri With Dr.
___________________________ Please call if you
need to reschedule your appointment. Dont forget
to go to the lab about a week prior to your next
visit for blood work.
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Appointment Card(Back)
Do You Know Your Targets? HbA1C lt
7.0 Blood Pressure lt 130/80 LDL lt 100
mg/dl Fasting Glucose 80 110 mg
/dl Triglycerides lt 150 mg/dl 2 hr postprandial
glucose lt 140 mg/dl Annual Eye Exam Annual
Urine Test Daily Aspirin Foot Exam at least
annually Nutrition consult Self Management
Education Tobacco Cessation Thyroid test
periodically Flu Shot annually Pneumovax at
least once Tetanus every 10 years Visit at least
every 6 months (good control)
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Lab and Pharmacy

• Pt picks up any new medications or refills
• Any additional blood work is drawn by the lab
• Pt is notified prior to going home that blood
  work for next visit is already ordered and she
  can come in a week before her appointment to have
  it drawn

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Informed Patient on the Team

• Knows what is expected
• Has his targets
• Has an appointment
• More likely to engage

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If Patient Doesnt Show Up?
Hi Mr. Davis. This is Jim in the Family Medicine
Clinic. I noticed you missed your follow up
appointment for your diabetes. I wanted to call
and reschedule that appointment for you if you
like.

• Process Starts Over
• Jim notes that patient missed the appointment
• Calls patient to reschedule

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Keys to Successful Disease Management

• Prepared, Proactive Team
• Clear Standing Orders for Team Members
• Multidisciplinary Approach to care
• Reminders built into the system
• Aware, Responsive Patient
• Periodic assessment and reengineering of clinical
  business processes

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Questions