Margarita, a patient with diabetes, is 48, but says that sometimes she feels like she’s 80. “My nurse calls me like clockwork,” says Margarita* of the diabetes nurse who phones her on behalf of her Medicaid program. “She always points out the positive stuff I’m doing. To me that makes a big difference. She advocates for me and tells me what’s best.”

Darren and Margarita are just two of the more than 90 million Americans who live with chronic diseases.1 Chronic diseases are responsible for seven out of 10 deaths in the United States, claiming 1.7 million lives each year.¹ Over 75% of the $1.4 trillion spent on health care annually is for people with chronic diseases.¹ Chronic diseases afflict young and old alike, accounting for about one-third of the years of potential life lost among people younger than 65.¹

Many of these patients experience a poor quality of life, a life of confusing and often conflicting information about medications and treatments garnered during hasty questioning of harried healthcare providers. Enter disease management (DM), one of the fastest-growing trends in healthcare. Dozens of state Medicaid programs and many private health insurers have turned to DM in an effort to improve quality and reduce costs for members. At its best, DM benefits patients and payers alike.

Disease management defined

The overall goals of DM are to measurably reduce complications associated with selected chronic diseases and to improve the overall quality of life for patients in DM programs. Many programs are telephonic and involve registered nurses. Some include other healthcare providers, such as social workers, LPNs/LVNs, pharmacists, and dietitians. Nurse case managers may provide in-home visits, arrange for durable medical equipment, and coordinate other needed care in conjunction with DM nurses.

The process typically begins when a payer —  the public agency, insurance company, or employer group that pays the healthcare bills — identifies a patient with a targeted disease, for example, diabetes. The patient can be identified by coding on hospital and medical claims, as well as by pharmacy and laboratory claims. The patient’s demographic information may be sent to one of the many companies offering DM programs or to the organization that will provide the services.

Typically, the RN contacts the patient by phone. Participation in the program is voluntary. If the patient agrees, the nurse performs an initial assessment similar to the first visit to a physician’s office. Using standardized evidence based guidelines, the nurse discusses the recommended medical care and lifestyle behaviors proven to reduce complications and produce the best outcomes. While the most common DM model involves nurses working out of call centers, other DM models are being developed that are community or clinic based, or a blend of field and telephonic nurses working closely with provider offices.

According to the Disease Management Association of America , “Disease management is a system of coordinated healthcare interventions and communications for populations with conditions in which patient self-care efforts are significant.”² According to the DMAA, the disease management process:²

• Supports the physician or practitioner/patient relationship and plan of care.
• Emphasizes prevention of exacerbations and complications using evidence-based practice guidelines and patient empowerment strategies.
• Evaluates clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall health.

The DMAA says that a disease management program must include the following components. (Those that don’t should be considered disease management support services):²

1. Population identification processes: Programs must identify patients with the target disease through methods such as claims and provider referrals.
2. Evidence-based practice guidelines: The program must use evidence-based clinical practice guidelines developed by physicians and reputable specialty organizations.
3. Collaborative practice models to include physician and support-service providers: Physicians are informed of their patients’ participation in DM programs and may receive reports about their progress. Nurses in some DM programs are authorized to contact the physician directly if the patient has a current problem that could lead to complications in the near future, such as unreported symptoms or lack of needed prescription refills. Most physicians recognize the validity of practice guidelines and have no objection to nurses using those parameters for education and intervention. A telephonic nurse triage or advice-line service, which further reinforces the patient/provider relationship, is often an integral part of a DM program.
4. Patient self-management education (may include primary prevention, behavior modification programs, and compliance/surveillance): The crux of DM programs is the nurse-patient interaction, which closely follows the nursing process. After the nurse has assessed the patient, they will set goals and plan for future calls together. Subsequent calls include educational interventions such as teaching about disease pathophysiology, medications, and lifestyle changes. Evaluation is ongoing as the nurse monitors such outcomes as medication compliance, physician visits, laboratory results, and factors such as diet and weight management, if needed.
5. Process and outcomes measurement, evaluation, and management: The DM organization measures success by improvements in clinical and behavioral outcomes, and prepares periodic reports documenting those changes. The quality of the nursing process is evaluated as well.
6. Routine reporting/feedback that may include communication with the patient, physician, health plan, and ancillary providers and practice profiling: The DM organization shares reports with applicable providers and payers on an ongoing basis. The reports may document such factors as improvements or changes in patient outcomes, patient satisfaction, and return on investment, i.e., how much money did the DM program save the payer compared to the cost of the program?

What diseases?

In 2003, the Institute of Medicine identified 20 priority areas deserving of national attention and financial resources to improve healthcare for millions of Americans.³ These include chronic conditions such as asthma, diabetes, hypertension, ischemic heart disease, and major depression.³ The CDC also identifies five chronic diseases — heart disease, cancer, stroke, COPD, and diabetes — as causing the most significant morbidity and mortality.²

It comes as no surprise that DM companies focus on diseases that are chronic, complex, common, and costly to manage. DM programs especially include conditions in which making relatively few changes can significantly improve quality of life for patients. In many cases, costs for certain segments of medical care such as emergency department visits and hospital admissions decrease, while costs for office visits and medications increase.

Diseases frequently selected for DM programs include asthma, heart failure (HF), COPD, coronary artery disease, depression, diabetes, and renal failure. Another criterion for a disease to be included in a DM program is that widely accepted clinical practice guidelines are available. Consider these three diseases common to most DM programs:

Asthma. Commonly used guidelines: National Heart, Lung, and Blood Institute Guidelines for the Diagnosis and Management of Asthma.⁴ www.nhlbi.nih.gov/guidelines/asthma/execsumm.pdf In 2004, the latest year for which there are complete figures, an estimated 20.5 million Americans had asthma — 6.2 million are under age 18.^5,6 About 11.7 million people (57% of those with asthma) had at least one asthma attack that year.⁵ Asthma was the cause of 1.8 million visits to the ED in 2004 and cost the economy about $11.5 billion in direct and indirect healthcare costs.⁵ Clearly, there is a long way to go in improving the management and care of asthma patients, one reason why asthma is often chosen to be part of a disease management program. Also, patients tend to be younger and many are otherwise healthy. Parents of children with asthma are highly motivated to reduce symptoms and improve the quality of life for their asthmatic children.

While disease management programs vary according to the organization managing the program, a typical program may work in the following way. Once an appropriate patient has been identified, an ancillary staff member calls to explain the program to the patient and to enroll him or her. In the case of asthma, contact often will be with the parent or guardian of a child with asthma. If the patient agrees, an appointment is set for the nurse to contact the patient (or parent).

The nurse will ascertain educational needs during the initial assessment and will, in concert with the patient, set goals for future calls. For example, it is not unusual for asthma patients to be confused about how and when to use medications and that may be a focus of the first calls. Depending on the severity of the asthma, measurable clinical outcomes could include daily use of inhaled corticosteroids or other controller medication, and a short-acting beta2-agonist rescue inhaler (e.g., albuterol). The nurse may instruct the patient or parent in the use of a peak flow meter to monitor pulmonary function and about the importance of having an asthma action plan. (See the American Lung Association’s sample asthma action plan at www.lungusa.org/atf/cf/%7B7A8D42C2-FCCA-4604-8ADE-7F5D5E762256%7D/AAP.PDF). Other teaching might include information about the identification and avoidance of environmental triggers (smoke, dust, pollen, animal dander, etc.); the value of using spacers with certain inhalers; and the importance of keeping a rescue inhaler at school or work, in addition to one at home.

Heart failure. Commonly used guidelines: American College of Cardiology/American Heart Association 2005 Guidelines for the Evaluation and Management of Chronic Heart Failure in the Adult.⁷ An estimated 5 million Americans have heart failure, and over 550,000 are newly diagnosed with it each year.⁷ HF accounts for up to 15 million office visits and 6.5 million hospital days annually.⁷ The incidence of HF is increasing because more patients survive myocardial infarctions and because the population is aging, both factors in the development of this disorder.⁷ 

Patients with HF offer many educational opportunities for the DM nurse. Using evidence-based guidelines for HF, the nurse will find many patients are on angiotensin converting enzyme inhibitors (ACE inhibitors), angiotensin receptor blockers (ARBs), beta-blockers, digitalis, and diuretics.⁷ Depending on patient symptoms and HF classification, other medications also may be recommended. The DM nurse will work with patients to ensure they understand the importance of adhering to their medication regimen, monitoring salt intake, and receiving pneumococcal and influenza vaccinations. Some DM plans provide scales and blood pressure monitors to patients with HF. Such inexpensive and low-tech interventions encourage patients to weigh themselves daily and to take periodic blood pressure readings, both common measures of DM outcomes.

Diabetes. Commonly used guidelines: American Diabetes Association Standards of Medical Care in Diabetes — 2007.⁸ About 7% of the population, or 20.8 million Americans, have diabetes.⁹ Nearly one-third of those people — about 6.2 million of them — don’t know that they have it.⁹ Diabetes carries a huge burden of disability because of the serious complications, such as heart disease, renal failure, blindness, and amputation. The total annual economic cost of diabetes is estimated to be $132 billion or about one out of every 10 healthcare dollars spent in the United States.⁹ Unfortunately, because Americans are becoming increasingly heavier and less physically active, the incidence of diabetes is rising.

Patients with diabetes can greatly benefit from participation in DM programs. Their complex disease process requires frequent medical exams and laboratory tests (such as periodic measurement of Hgb A1C, a measurement of blood glucose over three months; lipids; and renal function). People with diabetes are encouraged to have annual eye, foot, and dental exams to screen for diabetic retinopathy, neuropathy, and infections. Nursing education would include the importance of monitoring blood glucose and blood pressure at home, daily self-examination of the feet, and the importance of pneumonia and flu vaccinations.

Much of the DM nurse’s efforts will focus on the benefits of medication adherence as the patient with diabetes will be on a number of nondiabetic medications, which may include statins, aspirin, antihypertensives, and cardioprotective medications, such as ACE inhibitors or beta-blockers. The DM nurse will also spend considerable time encouraging the patient to adhere to the prescribed diet and exercise programs. And as diabetic patients experience twice as much depression as the general population, nurses should monitor for symptoms of depression in patients with diabetes (as well as in patients with other chronic illnesses).¹⁰

Getting results

Around the nation, public and private payers are integrating disease management programs into health plans. Numerous health plans, including HMOs and Blue Cross/Blue Shield plans, offer DM services. Many states have added DM programs to their Medicaid plans, including California, Florida, Illinois, Maryland, Mississippi, North Carolina, Oregon, Texas, Virginia, and Washington. While some states contract with DM organizations, others start their own programs. For example, Indiana developed a DM program called Indiana Chronic Disease Management Program for its Medicaid patients, phasing in services for asthma, diabetes, HF, coronary heart disease, hypertension, and renal failure over several years.¹¹ Like many DM programs, the Indiana program stratifies its members into high and low risk, and delivers services accordingly; for example, nurses may contact high-risk patients more frequently while ancillary healthcare staff contact the low-risk patients.¹¹ 

Recognizing the merits of disease management, Medicare developed a number of trial demonstration projects to be established as part of the Medicare Prescription Drug Improvement and Modernization Act of 2003. First dubbed the Chronic Care Improvement Program, the program is now called the Medicare Health Support Project. Phase 1 of the program is under way, serving an estimated 180,000 traditional, fee-for-service Medicare beneficiaries with diabetes and heart failure.¹² According to the Centers for Medicare and Medicaid Services, about 14% of Medicare beneficiaries have HF and account for 43% of Medicare spending; the 18% with diabetes account for 32% of spending.¹²   

The Medicare Health Support programs are designed to reduce health risks, improve the quality of life, and provide savings to beneficiaries and to Medicare.¹³ Phase 1 will end in 2008. Depending on the results, Phase 2 may involve expanding the programs to additional beneficiaries in other locations who have the same conditions or it may add additional diseases to diabetes.¹³

For years, managed care organizations struggled to control burgeoning medical costs through rigorous utilization review programs in which every hospital admission, surgical procedure, and home care visit required prior authorization. The resulting backlash produced increased regulation of managed care organizations with numerous state and federal laws to protect patient and physician rights.

Unlike utilization review, which focuses on eliminating possibly unnecessary services (such as preoperative hospital days for elective surgery), DM focuses on ensuring that patients are getting the right care, such as taking their medications, getting their checkups and lab work, and sticking to diet and exercise plans. By concentrating on doing the “right things” rather than eliminating the “wrong things,” disease management often achieves cost reductions as well as improved quality of care without the contentious exchanges between physicians and payers that were so common in the past.

Yet DM has achieved significant cost savings. One study of patients enrolled in a HF disease management program showed a 21% reduction in hospital admissions and a 20% reduction in death.¹⁴ Another demonstration project of a group of Medicare patients with HF resulted in an overall reduction in utilization of healthcare resources by 41%, ED visits by 33%, and hospitalizations by 29%.¹⁵ A school-based asthma DM program in Colorado resulted in a decrease in daytime asthma symptoms of 62% and of nighttime symptoms by 34%; additionally, missed school days and unscheduled visits to the physician fell by two-thirds.¹⁶ Indiana’s Medicaid DM program has saved an estimated $20 million as of late 2006.¹¹

But it’s not just about cost. Both real and perceived quality is high. For example, consider two studies of patients with diabetes participating in a DM program. One study of more than 36,300 patients showed a 29% increase in periodic Hgb A1C testing.¹⁷ The other study of over 67,200 patients with diabetes showed that telephonic contacts by DM nurses resulted in a 32.5% reduction in LDL, even when the target was as low as 70 mg/dL.¹⁸ These are significant measures of quality of care for patients with diabetes.

Patients seem to appreciate DM programs. Participants report that they feel they have more control of their health and can better communicate with their providers.¹⁹ In one program, more than 95% of eligible members elected to participate even though participation was voluntary.¹⁹ Another survey showed that DM enrollees reported high satisfaction with their health plan, along with improved social functioning (even though the health plan did not save any money).²⁰ 

What’s in it for nurses?

Nurses working in DM programs enjoy something that’s found all too seldom in today’s busy hospitals: time for teaching. Because nurses are highly regarded by the public, they have an exceptional opportunity to directly affect patients’ lives and health. Using approved clinical practice guidelines, DM nurses teach patients about behavioral changes necessary to produce optimal outcomes. Actions as simple as having people log daily blood glucose levels, weights, or peak flow meter readings can demonstrate to patients how day-to-day activities can positively affect their disease. Nurses can encourage patients to take lists of questions to their healthcare providers so that important details aren’t forgotten in the rush.

The growth of disease management offers a new career opportunity for nurses, one that concentrates on using widely accepted practice guidelines and intensive personalized telephonic intervention to achieve improved clinical outcomes. The downside for some nurses may be the reliance on telephonic and computer technology rather than hands-on care. With practice, listening skills improve, making up for the lack of visual contact. Most patients are delighted at the opportunity to talk to nurses about their conditions. Many have unresolved questions left over from visits to their healthcare providers.

Disease management is beneficial for patients, providers, and payers alike. Through education and coaching, nurses can give patients the tools to make the right decisions and better manage their chronic diseases. Nurses can help patients interact more effectively with their healthcare providers. These interventions are proven strategies that empower patients and improve lives. It’s a win-win situation for all!

*Patients’ names have been changed.