Automated referral creation, episode generation, assignment, and tasking means that staff no longer have to spend hours poring over longitudinal records to identify candidates for disease management programs. At the same time, each step of the interaction, assessment, and care planning process support manual overrides that enable staff to further personalize goals, barriers, and interventions. This intelligent design ensures proper guidance, support, and monitoring and provides the best opportunity to drive sustained behavior change.
Your population is made up of unique individuals who deserve care tailored to their specific needs. Effective disease management for the highest complexity individuals frequently necessitates a multidisciplinary care team that may include such roles as care managers, clinicians, pharmacists, behavioral health specialists, and social workers.
Appropriately managing individuals with chronic conditions means understanding their day-to-day lifestyle and self-care choices. The result is a complete picture of not only each individual's chronic conditions and comorbidities, but their entire set of interactions and gaps relative to the care continuum.
Ultimately, real-time integrations, remote monitoring, and automatic workflows lead to more appropriate and timely interventions. Science Explorer. Mission Areas. Unified Interior Regions. Science Centers. Frequently Asked Questions. Educational Resources. Multimedia Gallery. Web Tools. Board on Geographic Names. The National Map. USGS Library. USGS Store. Park Passes. News Releases. Featured Stories. For example, a physician who diagnoses and treats a patient with congestive heart failure CHF may believe he or she has fulfilled their responsibility once the patient's symptoms are resolved.
The physician would then prescribe appropriate medications and suggest ways to manage CHF symptoms. Generally, physicians or other health care professionals only have the opportunity to evaluate patients when the patient complains of symptoms, when the patient is seen during an office visit or when the patient is hospitalized.
By contrast, disease management programs focus on multiple facets of patient care and maximize the health status of defined patient populations. Successful disease management programs coordinate care for the disease among all providers, physicians, pharmacists, hospitals and laboratories.
They also develop and implement a partnership with patients, because all of these individuals understand the value and relative contribution each brings to the program.
Managed care organizations are well positioned to practice disease management because they are dedicated to comprehensive, coordinated care. They focus on improving the health of entire patient populations, use available resources effectively, and are held accountable by patients, purchasers and regulators for the quality of their medical services.
Managed care organizations integrate key health care services, including patient and health care professional education, as well as ambulatory care, acute care, home health care and nursing home services. Such integration provides greater continuity of patient care, leading to better health care outcomes. Health outcomes affect both the quality of life and the use of health care services. Disease management programs are objectively evaluated based on previously defined outcome points and the collection of baseline data on the natural course of the targeted disease.
Performance indicators and outcome measures should be analyzed to determine if the program is achieving quality improvement. Performance indicators assess a specific performance at regular intervals and compare performance to predefined indicators.
These indicators measure the intermediate success of an action or intervention. Outcome measures determine the end result of an action or intervention.
Obtaining meaningful outcomes should improve the overall quality of the program. Health outcomes can be measured from several perspectives:. Based on continuous, objective evaluation by health care professionals, the most effective programs are retained. Marginally effective or ineffective programs are either modified or abandoned.
In discussions involving patient care, a common question that arises is the distinction between disease management programs and medication therapy management MTM programs.
Medication therapy management is a distinct service or group of services that optimize therapeutic drug outcomes for individual patients. MTM services are independent of, but can occur in conjunction with, the provision of a medication. MTM programs are not intended to focus on one disease state but cover the full spectrum of medications a specific patient may be taking.
Pharmacists are important team members of the disease management process. As members of the health care team, pharmacists can provide education, as well as screening and medication monitoring services.
0コメント