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Disease management matures an organization's quality improvement program in today's competitive health care environment by combining a disease-focused, multidisciplinary, systematic, data-driven, patient-centered approach to clinical process improvement. With the advent of managed care, the disease management movement has been catalyzed (Donagher &Aforismo, 1996). As managed care penetration increases in a health care market, there is a shift in priorities focusing on the health care continuum, care of populations of people, quality, and maintaining wellness. There is a marked focus on value, the balance between clinical quality outcomes and cost. Priorities shift with the degree of managed care market penetration (see Figure 1) until in mature managed care markets, contracts are partially negotiated based on quality outcomes from disease management programs.
An overview of the concepts of care management, case management, and disease management enables adult-health nurses to develop and evaluate effective programs. Disease management's impact on improving clinical and economic outcomes can be illustrated using asthma as a model. Further, the Joint Commission on Accreditation of Health Care Organizations' (JCAHO) quality improvement framework of Plan, Do, Check, Act can be used to guide the disease management study process.
Core Concepts
Disease management is defined by Moss (1997) as population management that looks at all interventions a patient would need in managing a chronic disease for which he or she is diagnosed, or at high risk for, using data-driven comprehensive measurements that span the continuum of care. The goals of disease management are to provide information to guide the decisions of patients and clinicians along a route of care that alters lifestyle patterns, provides education, and produces better care outcomes (Schaffer & Behrendt, 1997).
Disease management is a component of care management. Care management systems are designed for populations of people in aggregate. Care management is the strategic coordination of clinical systems across the care continuum that promotes value in a competitive health care environment. Care management has two components: case management and disease management. Case management focuses on processes by which experienced clinical professionals work with individual patients, providers, and payers to coordinate all the services deemed necessary to provide patients with appropriate health care across the continuum. Patients who are in need of case management, those who are potentially high users of the health...