Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 126Disease Management Version 3.0Medical Management GuideBased on contractual agreements, the MTF mayalso collaborate with the local MCSC in providinga seamless program between the DCS and PCS.Implementation must be a healthcare team effortthat incorporates all available resources to avoid“reinventing the wheel.”3. Adopt Guidelines and ProtocolsThe healthcare team may decide to implement adisease-specific guideline and adapt it to facilitatelocal policies, business plan initiatives, or Commanddirectives. Prior to implementing a CPG, teammembers will need education and training in theapplication of the algorithm(s) and toolkits. This willmost likely involve reengineering MTF processes tomobilize the entire healthcare team. Roles will needto be assigned so that all personnel understand theirrole(s) in the process (e.g., appointing a providerchampion). Other methods — such as the use offlow charts, lists, and the PDCA cycle (refer to Fig.33) — can help in designing, tracking, andcommunicating the processes to all participants.The steps taken in developing and/or choosing anappropriate CPG should be documented in Servicespecificexecutive/leadership functional minutes,Population Health committee minutes, or MTF policy.4. Establish Goals and Target OutcomesIn establishing goals and targets, it may be helpfulto look at prior performance, MTF trends, Commandexpectations and available resources. Targets shouldmirror the common project management approachSMART — that is, be specific, measureable,achievable, realistic, and time-bound. The diseasemanager, in collaboration with the interdisciplinaryhealthcare team, may develop a timeline formonitoring the status of the population selectedby the team. For example, a desirable goal maybegin with notifying patients overdue for diabetichemoglobin A1C testing and encouraging them tocomplete laboratory tests within 60 days of DM planimplementation.Example of an Interdisciplinary Healthcare Team• Providers (physicians, physician assistants,nurse practitioners)• Registered Nurses (RNs)• Health educators• Technicians, medics, medical assistants/clerks• Utilization management (UM) and CaseManagement (CM) staff• Any ancillary and allied healthcare staffwho participate in managing the targeteddisease/condition (e.g., pharmacists,nutritionists, dental hygienists/dentists)• Command leadership• Information management/technologyspecialistsFig. 36 – Example of an Interdisciplinary Healthcare Team
Medical Management GuideVersion 3.0Disease ManagementPage 1275. Create a Prioritized Plan6. Implement the PlanIn these two phases, the disease manager focuseson selected patient groups previously identified bythe healthcare team and helps the team determinethe decisions and tasks that need to occur and theorder in which they should be executed. Individualand family education is just one type of interventiona disease manager can use to promote patient selfmanagementin an effort to minimize complicationsand avoid unnecessary and inefficient healthcareutilization. Other strategies are to send reminderpostcards or use automated telephone messagingsystems to notify patients of the need for healthcarevisits, medication changes, or recommendedbehavior changes. These techniques offer a simpleyet effective way to collaborate with patients inreaching their desired treatment goals.7. Collect and Analyze Outcomes DataThis phase should be accomplished at regularintervals to track progress. The disease manageris encouraged to liaison with other members ofhis/her Command (e.g., business office, qualitymanagement, IT) to determine whether this datacollection is already occurring at the MTF, or toleverage existing resources or expertise.8. Evaluate and Refine the ProgramDuring this phase, the disease manager may identifybarriers that are preventing the MTF from reachingits goals and determine the necessity of developinga plan to remove those barriers. It is critical thatthe MTF perform annual reviews to determine nextsteps and follow-on goals. Benchmarking againstinternal and external outcomes (e.g., applyingHEDIS ® measures) is a good method for trackingperformance and progress.AccreditationOrganizations such as URAC, the NCQA, and TJCprovide accreditation to DM programs. Otherdisease-specific organizations, such as the AmericanDiabetes Association (ADA), provide certificationsthat recognize outstanding educational programsbased on national standards. (Based on the NDAA2007, it is the MHS’ policy to promote meetingthe standards for program accreditation but notnecessarily for programs to become accredited.The topic is included here to increase awareness ofaccreditation possibilities.)URAC has established accreditation standards forDM programs. According to URAC, DM standardspromote evidence-based practice, collaborativerelationships with providers, consumer education,and shared decision-making with consumers. Thesestandards apply to all types of entities providingservices for individuals with chronic illnesses,including health plans and freestandingDM or MM organizations.The URAC accreditation process occurs in fourphases:1. Application2. Desktop Review3. On-site Review4. Committee Review
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