Medical Management Guide, 2009, Version 3.0 - Tricare

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Page 128Disease Management Version 3.0Medical Management GuideThe NCQA offers program accreditation options toinclude various patient- and practitioner-orientedprograms. The NCQA’s DM standards address keyareas for which organizations are reviewed. Thestandards are based on patient service, practitionerservice, program content, clinical systems,measurement and quality improvement, andprogram operations.TJC certifies DM programs as a complementaryprocess to MTF accreditation. TJC’s Disease-SpecificCare (DSC) Certification Program is designed toevaluate DM and chronic care services that areprovided by health plans, DM service companies,hospitals, and other care delivery settings. The evaluationand resulting certification decision is basedon an assessment of the following:• An organized approach to performancemeasurement and improvement activities.• Compliance with consensus-based nationalstandards.• Effective use of evidence-based CPGs tomanage and optimize care.For organizations, TJC accreditation is available forvirtually any chronic disease or condition. Advancedaccreditation is available for chronic kidney disease,inpatient diabetes, primary stroke centers, and otherspecialized disease states/procedures.THE DISEASE MANAGEMENTPROFESSIONALQualificationsThe job description of the DM professionalwill vary depending on the size of theMTF and the availability of resources.DM professionals should possess sufficientclinical knowledge and patient care experienceto identify appropriate use of and compliancewith CPGs, as well as conduct and/or arrangepatient care. The DM professional also needsexcellent communication skills, as he/she worksin collaboration with a range of healthcarepersonnel to promote delivery of appropriate,cost-effective care to patient populations.Typically, a candidate for the disease manager rolecan best succeed with the following qualificationsor commensurate experience:• A bachelor’s degree (or higher) in a healthrelatedfield from an accredited institution.• A valid unrestricted healthcare license.• Current basic life support (BLS) certification.• Experience with software and databasescurrently employed at the MTF.• Strong communication and organizational skills.Desirable qualifications include:• Certification by the HealthSciences Institute(HSI) through its Chronic Care Professional (CCP)certification program or another disease-specific,patient-education certifying institution (e.g.,American Diabetes Association [ADA]). (SeeCertification, next page.)
Medical Management GuideVersion 3.0Disease ManagementPage 129• Familiarity with evidence-based CPGs andUSPSTF recommendations.• Familiarity with clinical quality measures (e.g.,HEDIS ® , ORYX).• Three years of broad-based clinical healthcareexperience.• Full-time employment in a healthcare role forthe previous 12 months.• Previous DM experience.The disease burden of the MTF’s enrolledpopulation will determine the size and specificityof any DM program. CD-ROM Resource ItemDM-6 provides a list of sample contract tasks for aDM nurse, which could be adapted to either astatement of work or another type of jobdescription. CD-ROM Resources DM-7,DM-8, and DM-9 provide sample Service-specificDM position descriptions.It should be noted that, depending on the particularService or MTF, DM responsibilities or oversightmay be included as part of roles such as ClinicalStaff Nurse, Physician, or Health Care Integrator(HCI) — an Air Force-specific position ( CD-ROMResource DM-10 provides a description of the HCIrole).CertificationThe HSI has offered a CCP certification programsince 2004. In October 2007, the DMAA partneredwith the HSI and endorsed the program, whichencompasses 25 chronic diseases and late-lifeconditions. The program promotes an evidencebasedapproach to leveraging Population Healthstrategies, DM practices, and health coaching.CCP certification is valid for three years. Recertificationthrough re-examination or documentation of 15 hoursof continuing DM or chronic care education may beobtained. Additionally, organizations that requireCCP for their professional staff may include the CCPseal on their promotional materials, proposals, andwebsite documentation to demonstrate to patientsand customers that their staff have completedspecialized training and passed a national examination(i.e., to show the organization is CCP-accredited).SUMMARYClosely linked to Population Health, DMfocuses on fostering consistent, evidencebasedcare for beneficiaries with one ormore chronic diseases or conditions. While the roleof DM may have been underappreciated in the past,expanded IT capabilities and a renewed appreciationfor the impact of chronic disease on the individual andthe healthcare system have served to highlight theproactive role DM plays in improving the future healthof defined populations.To promote program goals and reduce duplicationof efforts, DM must be accomplished in concert withboth UM and CM staff and the entire healthcareteam. Strategies for implementing DM shouldincorporate other policies and program documents,such as the 2006 Department of Defense Instruction(DoDI) 6025.20, Medical Management Programs inthe Direct Care System (DCS) and Remote Areas (seeSection I, Medical Management Essentials,CD-ROM Resource MME-1), and the currentedition of the DoD Population Health ImprovementPlan and Guide (see Executive Summary,CD-ROM Resource ES-1).
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