Medical Management Guide, 2009, Version 3.0 - Tricare

Medical Management GuideVersion 3.0Disease ManagementPage 125EVALUATEEvaluateand Refinethe ProgramASSEMBLEAssemble aTeamADOPTAdoptGuidelines andProtocolsANALYZECollect and AnalyzeOutcomesDataASSESSAssessthe TargetPopulationESTABLISHEstablish Goalsand TargetOutcomesIMPLEMENTImplementthe PlanCREATECreate aPrioritizedPlanFig. 35 – The Phases of Implementing a Disease Management Planmanager is ready to focus on implementing aspecific plan. An eight-phase approach providesa systematic construct to help stakeholdersbecome comfortable with the processes of planimplementation. Fig. 35 summarizes the phasesinvolved in setting up a DM plan.Let’s break each phase down to get a more preciseappreciation of what the disease manager shoulddo at each level:1. Assess the Target PopulationFor example, consider a chronic disease such asdiabetes mellitus: How many patients are enrolledand to which providers are they assigned? Thedisease manager may further risk-stratify thepopulation to examine glycemic control, overduelab tests, and associated co-morbidities.2. Assemble a TeamThis phase allows the disease manager to presentthe clinical data identified in Phase 1 to thehealthcare team that will be managing the diseases/conditions. Collaboration and communication arecrucial in identifying the best way to assist a patient/group of patients in adhering to the treatmentplan(s) and in taking more control and responsibilityfor their own health care. Phase 2 teams should beinterdisciplinary, including providers, nursing staff,MM, and ancillary support personnel (see Fig. 36).