Disease Health Management MTF Road Map

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Disease (Health) ManagementMTF Road Map Action
Plans

• CDR Cynthia J. Gantt NC, USN, FNP, PhD
• Director Population Health and Medical Management
• TRICARE Management Activity
• 16 March 2008

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At the end of this session, the learner will be
able to

• develop an effective action plan using the
  Military Treatment Facility Road Map for
  Successful Disease and Condition Management that
  directly supports the MTF business plan and
  evidence based health care sections of the
  performance based budget.

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DMAA Disease Management Required Components

• Population identification processes
• Evidence-based practice guidelines
• Collaborative practice models to include
  physician and support-service providers
• Patient self-management education
• May include primary prevention, behavior
  modification programs, and compliance/
  surveillance

DMAA.org
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DMAA Disease Management Required Components

• Process and outcomes measurement, evaluation, and
  management
• Routine reporting/feedback loop
• May include communication with patient,
  physician, health plan and ancillary providers,
  and practice profiling
• Note Full-service disease management programs
  MUST include all six components. Programs
  consisting of fewer components are disease
  management support services.

DMAA.org
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Framework Required
http//www.improvingchroniccare.org/index.php?pTh
e_Chronic_Care_Models2
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The Chronic Care Model

• Community Resources Policies
• Health System Organization of Health Care
• Self-management Support
• Delivery System Design
• Clinical Information Systems
• Decision Support
• Informed, Activated Patient!
• Prepared, Proactive Practice TEAM!

Wagner, E. H. (2001). Meeting the needs of
chronically ill people. BMJ, 323, 945-6.
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MTF Road Map for Successful Disease Condition
Management

• 1. Leadership
• 2. Clinical Practice Guidelines Metrics
• 3. Disease Condition Management Reengineering
• 4. Program Deployment Evaluation
• 5. Education
• 6. Marketing

Meyers Padden (2001)
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1. Leadership (Support)

• ALL LEVELS!
• Directors (Governing Board/ESC) provide oversight
  support
• Commands strategic plan
• Periodic formal evaluation
• Analyze return on investment cost avoidance
• Clinical Champions Program Coordinators
• Formal (chartered) disease/condition specific
  teams
• Department Heads
• Physician Clinical Opinion Leaders

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2. Clinical Practice Guidelines Metrics
Systematically developed statements to assist
practitioner patient decisions about
appropriate health care services for specific
clinical circumstances. Institute
of Medicine, 1992

• Reduce variation errors (pt safety)
• Assure appropriate amount of care
• Ensure accountability

• Ensure predictable/ consistent quality
• Improve resource utilization
• Guide learning (pts staff)

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https//www.qmo.amedd.army.mil/
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3. Disease Management Reengineering

• Where the rubber meets the road many folks get
  stuck
• Clinical AND business processes reviewed
• Multidisciplinary perspective required!
• Teambuilding skills a must
• Process mapping, patient-centered flow charting
• Reengineered to optimize existing staffing
  resources WHO is going to contact these
  patients?
• Health care team (e.g., nurses, pharmacists)
  clinics
• Group visits

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NMCSD Population-Based Health Care Delivery
Model
Chartered Population Health Clinical Quality
Teams (CQT) Identify-Educate-Implement- Evaluate
Sustain Clinical Outcomes, Metrics Tools

• Targeted
• Populations
• Diabetes
• Asthma
• Chronic Heart Failure
• Breast Health
• Weight Mgmt
• Combat Casualty
• Cancer
• Tobacco
• Pneumonia

Office of Clinical Quality Coordinates
Collaborates with CQTs, CMTs Dept of Clinical
Decision Support Provides Training Support to
Clinics Command-Level Analysis
Evaluation
Clinic Management Teams Execute-Analyze-Initiate
Best Clinical Business Practices Evaluate
Healthcare Team Performance using Clinical Metrics
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Help Managed Care Support Contractors DM
Programs

• Required to develop and implement Asthma, Heart
  Failure and Diabetes opt-out DM programs
• Includes MTF Prime enrollees! (Always have)
• MCSC DM programs can be complementary for DM
  efforts at MTFs (staff shortages, budget
  constraints related to educational materials)
• MCSCs bring expert clinicians who can spend
  considerable time with individual beneficiaries
  premiere educational materials
• A system-wide approach requires collaboration
  coordination ongoing communication
• PLEASE contact your TRICARE Regional Office!

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4. Program Deployment Evaluation

• Plan for effective deployment
• Internal (staff) and External (patients)
• Aware and knowledgeable about the program
• Roles of the individual staff members are
  clarified (formal clinic management team
  structure helps a lot!)
• CONTINUOUS process (PDCA/PDSA) in place to
  monitor performance of the program

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5. Education

• Staff and provider education
• New disease/condition management business
  processes
• On-line BUMED toolkits
• Education is provided along with feedback on
  performance to the care team
• Providers not meeting standards are reviewed
  mentored by clinical champions
• Patient education regarding clinical processes
  (CPG) and self-management

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Web-based Training http//mhs.mhslearn.info/cha
rleston
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Education Self Management
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6. Marketing

• Specific marketing plan to providers, healthcare
  team members AND patients
• Do not leave until the last minute!
• Have an official Kick-Off
• Get leaderships support and official
  endorsements
• NEVERENDING!

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What the Road Map Can Do For You Your Command

• Organize (do more things simultaneously)
• Prioritize required actions
• More effectively communicate educate
• Up AND Down the chain
• Monitor Progress
• Sustain (despite deployments, rotations)
• Turnover Tool
• Expand to other conditions!

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Disease-specific Action Plan
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NMCSD Road Map Results Summer 2007
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Think Populations, See Individuals
Navy Environmental Health Center (NEHC)
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References Resources

• Chronic Care Model http//www.improvingchroniccar
  e.org/change
• Wagner EH. Chronic disease management What will
  it take to improve care for chronic illness?
  Effective Clinical Practice. 199812-4.
• Wagner, E. H. (2001). Meeting the needs of
  chronically ill people. BMJ, 323, 945-6.
• E.H. Wagner, B.T. Austin and M. Von Korff,
  "Improving outcomes in chronic illness," Managed
  Care Quarterly 4 (1996) (2) 12-25.
• M. Von Korff, J. Gruman, J.K. Schaefer, S.J.
  Curry and E.H. Wagner, "Collaborative management
  of chronic illness," Annals of Internal Medicine
  127 (1997) 1097-1102.

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References Resources

• Ginsberg B. Preliminary Results of a Disease
  Management Program for Diabetes. JCOM, 1996.
  3(4) p 45-51.
• Rossiter L, et al. The Impact of Disease
  Management on Outcomes and Cost of Care A Study
  of Low-Income Asthma Patients. Inquiry, 2000.
  37p 188-202.
• Rubin R, et al. Clinical and Economic Impact of
  Implementing a Comprehensive Diabetes Management
  Program in Managed Care. J Clin Endocrinol
  Metab, 1998. 83(8) p 2635-42.
• Wagner E, et al. Effect of Improved Glycemic
  Control on Health Care Costs and Utilization.
  JAMA 2001 285