Untangling Practice Redesign from Disease Management: How Do We Best Care for the Chronically Ill?

Abstract

In the past 10 years, a wide spectrum of chronic care improvement interventions has been tried and evaluated to improve health outcomes and reduce costs for chronically ill individuals. On one end of the spectrum are disease-management interventions-often organized by commercial vendors-that work with patients but do little to engage medical practice. On the other end are quality-improvement efforts aimed at redesigning the organization and delivery of primary care and better supporting patient self-management. This qualitative review finds that carve-out disease management interventions that target only patients may be less effective than those that also work to redesign care delivery. Imprecise nomenclature and poor study design methodology limit quantitative analysis. More innovation and research are needed to understand how disease-management components can be more meaningfully embedded within practice to improve patient care.

A Comparison of Health Plan- and Provider-Delivered Chronic Care Management Models on Patient Clinical Outcomes

“…When care management is embedded into the primary care practice, it will produce greater participation and improved clinical results as compared to usual care. 5,11 Our qualitative work 35 provides evidence that the PDCM approaches were highly variable across POs, likely with variable success. When averaged across all PDCM practices, the effects of specific strategies might have been masked or dampened…”

“…However, the latter has the advantage of integration and coordination with the patient's PCP, which may be key to improving health outcomes. [8][9][10][11][12] Although each of the two aforementioned approaches has been evaluated independently, there is a lack of studies comparing them directly. In addition, the literature is inconsistent with regard to outcomes in natural care delivery settings.…”

Improving Delivery of Bright Futures Preventive Services at the 9- and 24-Month Well Child Visit

“…This means that the team of providers and staff needs to be engaged. 6,7 One major tool for system change has been the quality collaborative, a group of practices or Dr Duncan helped in all aspects of the design, practice recruitment, and selection, learning session and follow-up call content, and recruitment of other learning session faculty. She reviewed data for improvement, wrote the first draft of the manuscript with Ms Pirretti, and did the 2 revisions with input from the other authors; Ms Pirretti had a leadership role in the project conceptualization, design, and implementation.…”

Results of a Mixed-Methods Evaluation of Partnerships for Health: A Quality Improvement Initiative for Diabetes Care

“…[3][4][5] It is hypothesized that a chronic disease management approach will enhance clinical processes, improve clinical outcomes, lead to a healthier population, and decrease the burden of chronic illnesses such as diabetes. 6 In Canada, 3 strategies have received considerable attention: (1) the development of new funding models to support a team-based approach 7 ; (2) the adoption of electronic medical records (EMRs) to improve documentation, surveillance, and provider collaboration 8,9 ; and (3) the promotion of clinical practice guidelines (CPGs) to encourage early screening and optimal treatment. 10,11 Implementation of these strategies unfortunately have faced many challenges, identifying the need for more effective and innovative programs to support primary health care providers in ameliorating their approach to diabetes care.…”

“…13,14 Thus far, evaluation of QI initiatives targeting diabetes have relied primarily on anecdotal and self-reported data, yielding varied results. 6,13,15,16 The challenges in evaluating complex programs like QI initiatives have been well documented and the need for more rigorous study designs identified. [17][18][19][20][21] Because randomized controlled trials are often not possible or inadequate for evaluating programs implemented in naturalistic environments, nonexperimental designs must be strengthened by using external evaluation teams, collecting data concurrently with program implementation, and providing a clear scope of the program.…”