Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 110Disease Management Version 3.0Medical Management Guideof population age distribution, gender, beneficiarycategory, risk factors, and disease burden. Diseasemanagers will also be interested in any knownhealthcare utilization patterns (e.g., high utilizers,inpatient admissions, Emergency Department [ED]visits).Tools to identify population demographiccharacteristics include:• Defense Eligibility Enrollment Reporting System(DEERS)• MHS Management Analysis and Reporting Tool(M2)• MHS Population Health Portal (MHSPHP)• Armed Forces Health Longitudinal TechnologyApplication (AHLTA)For more information, refer to Section V, MedicalManagement Tools.Armed with a thorough knowledge of theirpopulation, disease managers can risk-stratify thatpopulation and its healthcare needs in order todetermine the priority of interventions. This riskstratification includes identifying chronic diseaseconditions and required treatment along withdefining unhealthy behaviors within specific subpopulationsor cohorts.2. Evidence-Based Clinical Practice GuidelinesFundamentalsEvidence-based practice forms the foundation ofDM. DM programs use CPGs to guide patient care.What is the Military Health System Population Health Portal (MHSPHP)?The MHSPHP is a centralized, secure, Web-based Population Health management systemused by Army, Navy, and Air Force healthcare teams. The MHSPHP transforms Department ofDefense (DoD) and Network healthcare administrative data into actionable information.Military Treatment Facility (MTF) TRICARE Prime enrollees in need of potential clinicalpreventive services, Disease Management, or Case Management are identified on healthcareaction lists. MHSPHP documentation defines specific data sources and methodologiesthat are based on HEDIS ® parameters. Using the MHSPHP, all MTF healthcare teams canproactively manage the health status of their patients over the Web.
Medical Management GuideVersion 3.0Disease ManagementPage 111(CM and UM may also use CPGs as part of theirwork flow and patient care processes.)CPGs are systematically developed, evidencebased,nationally recognized statements to assistpractitioners and patients in making decisionsabout appropriate healthcare services for specificclinical circumstances (Field & Lohr, 1990). UsingCPGs as a tool is an important strategy in anyhealthcare organization, particularly where there isan opportunity to improve the quality of care andindividual patient quality of life, reduce variationin clinical practice, and decrease costs. CPGshelp standardize DM processes and may be usedas a framework for evaluating interventions byspecifying treatment goals and outcome measures(i.e., metrics). When successfully implemented,CPGs offer the opportunity for improving bothpatient clinical outcomes (by decreasing the rate ofcomplications) and financial outcomes (by reducinginappropriate utilization of healthcare services).In contrast to practices reflecting expert consensusor the anecdotal experiences of individual providers,evidence-based CPGs are explicitly linked to thestrength of evidence established after extensive andsystematic review of all relevant literature. CPGsmust be:• Clinically applicable and flexible.• Developed through an interdisciplinary process.• Reviewed on a scheduled basis.• Based on valid, reliable, and reproducibleevidence.• Well documented.CPGs are frequently displayed as an algorithm — aflowchart format providing step-by-step decisionsupport and care guidance for a specific diseaseor condition. CPGs are seen by many as a potentialsolution to inefficiency and inappropriate variationsin the quality of care. However, it is acknowledgedthat the use of guidelines must always be appliedin conjunction with a provider’s clinical judgmentfor the care of a particular patient. For that reason,CPGs may be viewed as an educational toolanalogous to textbooks and journals but presentedin a more user-friendly format.The MHS rationale for adopting CPGs is that theyprovide practitioners with a clinical decision-supporttool for determining appropriate evidence-basedhealth care for specific clinical conditions. A welldesignedguideline offers a broad approach tosupporting interdisciplinary, coordinated care forpatients with a variety of conditions. However,providers should be able to deviate from a guidelinewithout incurring sanctions or jeopardizing coveragefor services when, in their judgment, the healthcareneeds or desires of the individual patient indicatesuch a deviation.The Joint Commission (TJC, 2009) acknowledgesthat CPGs can “improve the quality, utilization, andvalue of healthcare resources.” The Commission hasincorporated their use into its standards for 2009,which state that leaders in hospitals (LD.4.240through LD.4.270) and ambulatory care facilities(LD.4.280) will use CPGs to design or improveprocesses that evaluate and treat specific diagnoses,conditions, and/or symptoms.The 2006 Department of Defense Instruction (DoDI)6025.20, Medical Management Programs in theDirect Care System (DCS) and Remote Areas (seeSection I, Medical Management Essentials,
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