Integration of Case and Disease Management

Abstract

Over the past several years, the healthcare industry has been struggling as a whole for effective ways to manage chronic disease and illness. In the US and in countries with socialized medicine, healthcare has either been rationed, restricted or had access limited to various healthcare services via traditional resource utilization approaches. In the US, utilization management approaches practiced by healthcare insurance companies, primarily Health Maintenance Organizations (HMOs), has suffered through a barrage of legal and regulatory hurdles as a result of consumer backlash to such restrictive programs. Thus, greater emphasis on case and disease management programs has emerged as a more progressive means for improving health outcomes in the chronically ill population.

A challenge confronting facilitators of these programs is the ability to integrate various case and disease management modalities into a seamless care management model that will yield optimal patient outcome opportunities. Case/disease management (CDM) can be best summarized as an ‘integrated’ approach to managing healthcare that identifies the optimal treatment approaches for patients with a specific disease and implements processes to afford compassionate and clinically evidenced-based care that will prevent disease complications and improve the health and quality of life of a given patient or patient population. However, depending on the facilitator of these programs (insurer, employer, independent vendor of services), CDM can have many different meanings and will vary in the scope, specificity and intensity of programs provided, as well as the level and extent of its major components.

An integrated program involves many considerations, such as: how an organization defines CDM and its true objectives, whether an effective infrastructure is in place to support it, what barriers exist that could potentially impede the program’s success, having the right technology to support outcome measurement and developing collaborative partnerships with providers, vendors and purchasers to streamline program costs and improve overall efficiency.

A description of the differences and similarities in CM and DM programs is given, including each program’s major components and how these models could evolve into a more integrated healthcare model. An overview of the most common care barriers is emphasized, affording careful consideration to healthcare design and how the current delivery system should be remodeled. A discussion of the utility and challenges of outcome management is put forth in order to aid CDM facilitators and other healthcare providers in futuristic outcomes planning and implementation.