Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 118Disease Management Version 3.0Medical Management GuideEach of these should be considered when planningcare with patients.Education materials should reflect an appropriatelevel of understanding for the patient/family and bepresented in their preferred modality and learningstyle. Education strategies include:• Individual and group classes on wellness or onspecific diseases or chronic conditions.• Patient-friendly written handouts.• Audio and video libraries.• Disease-specific telephone information centers.• Telephone prompts for screening or healthcareneeds.CD-ROM Resource DM-5 shows the WISEDisease Self-Care Model, which was developed bythe HealthSciences Institute (HSI) as a framework forpatient self-management.5. Process and Outcome Measurement,Evaluation, and ManagementThe critical evaluation of current programs andprocesses is an important element of both MM andPopulation Health. This evaluation can be appliedto all clinical departments within MTFs as diseasemanagers assess the health of the population, theimpact of clinical practices on care rendered, andthe quality and cost effectiveness of the deliverysystem.Quality of care can be measured by any number ofmeans, including:• Inpatient admission rates.• Emergency Department (ED) utilization.• Surgical outcomes.• Immunization rates.• Patient satisfaction.• Compliance with preventive health assessments.• Provision of recommended clinical preventiveservices.Process and outcome measures allow the diseasemanager to understand how the DM programis performing and to evaluate the impact ofimplemented actions on patient health.• Process measures evaluate specific aspects ofthe healthcare delivery practice, such as thepercentage of patients with diabetes with anA1c test completed in the past 12 months or thepercentage of patients with asthma who are onlong-term controller medication.• Outcome measures assess the results ofa specific test or how many patients areexperiencing a particular outcome (e.g., thenumber of patients with diabetes who had anLDL level less than 100 mg/dl).Clinical outcome measurements, such as processor outcome measures help gauge the progressof a DM program by improving specific aspectsof healthcare quality in the MTF. They areespecially useful in determining the effectivenessof a new program or of a specific aspect ofthat program. Tracking outcomes within anorganization provides a basis for modifyingprocesses to improve future outcomes and offersa mechanism for identifying barriers to desiredoutcomes.Disease managers should use standard, nationallyrecognized measures to enable goal-setting andbenchmarking — the review of processes, services,and clinical practices to compare performanceand gauge whether and where clinical processes
Medical Management GuideVersion 3.0Disease ManagementPage 119may need to be improved (see also Appendix C,Definitions). Benchmarking enables the followingcomparisons:• Among clinics/MTFs/services throughout anorganization.• Between the MHS and its civilian counterparts.• Against individual DM programs over time.These comparisons often allow for readyidentification or adoption of best practices whichmay prompt the re-engineering of clinical processesto ultimately improve the health of a population.Tools to readily collect healthcare information forspecific diseases or preventive services includethe MHSPHP, M2, AHLTA, and Clinical Data Mart,as well as Service-specific sites (see Section V,Medical Management Tools).Clinical Quality MeasuresA longstanding approach within the MHS hasbeen to leverage nationally recognized measuresto make comparisons to civilian benchmarks andorganizations. Numerous civilian organizations andgovernmental agencies have developed measuresof clinical quality and business efficacy. Theseorganizations include the CDC, TJC, NationalCommittee for Quality Assurance (NCQA), andAgency for Healthcare Research and Quality(AHRQ).The requirements for centralized MM measuresare developed through the MHS Clinical MeasuresSteering Panel, which includes representatives fromthe Services, MCSCs, and TMA.Healthcare Effectiveness Data and InformationSet (HEDIS ® ) —http://www.ncqa.org/Portals/0/HEDISQM/HEDIS2009/2009_Measures.pdfHEDIS ® is sponsored by the NCQA. As the mostwidely utilized set of measures of clinical qualityin health care, HEDIS ® is used by more than 90percent of managed care organizations throughoutthe United States. Using very explicit methodology(including age/gender/enrollment restrictions andinclusion/exclusion criteria), this set of standardizedmeasures specifies how health plans collect andreport data on quality of care. HEDIS ® measuresare frequently utilized by organizations to create a“report card” on the quality of services and careprovided by healthcare plans. These measures donot necessarily reflect the standard of care; rather,they serve to provide objective comparisons acrossorganizations.The HEDIS ® measures assess various dimensionsof care and services and are organized in eightdifferent domains encompassing more than 70different measures (refer to Fig. 29).The category the MHS leverages most to report onthe quality of care delivered to DoD beneficiaries isthe Effectiveness of Care (EOC) dataset. Measuresof interest to the MHS, including cancer screening,comprehensive diabetes care, and asthmamanagement, have been incorporated into thequality and business plans of all three Services andMCSCs. For a list of HEDIS ® EOC topics,refer to Fig. 30.
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