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C HAPTER 42 / Disease Management Models for Cardiovascular Care 925
individuals with multiple risk factors who are at greatest risk for used a group approach followed by individualized educa-
future cardiovascular events. Noting that it may be costly to in- tion. 39,53,54 A review of programs offering structured educational
clude all patients in disease management programs, organizations, interventions for cardiovascular disease 96 found that more than
such as Kaiser Permanente of Northern California, have focused two thirds of successful programs, many directed by nurses, were
their chronic disease efforts by subgrouping populations, offering focused on behavioral approaches directed at skill building.
lower-risk individuals educational and supportive services individ- Rather than providing information, these programs succeeded by
ually or in groups, and offering moderate-to-high risk individuals offering a range of health behavior skills, such as contracting, goal
what they term “care management.” Their experience is invaluable setting, self-monitoring, feedback, and problem solving. 97 Many
to those considering the development of disease management ef- used theories of stages of change, 98 social learning (most specifi-
forts. cally, self-efficacy), 99,100 and relapse prevention training 95,96,101 to
Once a population in need has been identified, it is critical to plan successful educational interventions. In addition, offering
learn as much as possible about the population. Knowing the de- educational materials in multiple formats (e.g., print, audio, and
mographic (age, gender, race, socioeconomic, and cultural) char- video) has also been shown to increase adherence to long-term be-
acteristics of the population being addressed enables one to struc- havioral changes. Adult learners differ in their preferred ways of
ture appropriate and effective interventions. Moreover, being gaining knowledge and skills and these multimedia approaches
sensitive to the educational, social, and cultural needs of the indi- giving them an opportunity for reinforcement of information. 97
vidual and populations is critical to success. Developing educational interventions based on the critical be-
haviors to be changed is key to successful disease management ef-
forts. For example, Stewart et al. 67 formulated a disease manage-
Coordinating Delivery Systems for ment program educating patients in a single face-to-face visit
Disease Management about medication use behaviors to improve heart failure out-
comes. The goal of the intervention was to focus on the problems
Although disease management models have operated in a variety
of settings including clinics, hospitals, and work sites, investiga- associated with medication adherence for each patient after hos-
tors have also used telephones and the Internet to deliver care pital discharge. With support of a pharmacist and a nurse in a sin-
and structure interactions with the patient to optimize care gle face-to-face visit in the home, Stewart planned an approach to
within the home setting. 43,92,93 Although there is much diver- manage each individual’s problems associated with medication use
sity related to structured interventions among these programs, and sought methods for improving adherence. Patients with mul-
most have incorporated patient education, multidisciplinary or tiple problems were offered additional support through telephone
physician–nurse teams, and specialized follow-up. Furthermore, calls by the pharmacist. At the end of 18 months and 4 years, this
the development of algorithms and protocols for delivering struc- disease management intervention resulted in decreased hospital-
tured care has been crucial to the success of disease management izations, improved survival, and lower cost associated with heart
68,102
systems. failure. The authors attribute the success of the intervention
Disease management involves a process of care delivery. Be- to the focused problem solving and tailoring for each individual
cause the process of care delivery is different from the typical patient and the additional efforts applied to more difficult pa-
67
structure within an office visit or hospital that is well known to tients through individualization of care.
most health care professionals; many different models for care de- The success of educational interventions for disease manage-
livery in disease management exist today. Although populations ment appears to be related to individualized approaches to educa-
differ, interventions have varied, such as a single face-to-face visit tion, offering multiple formats, use of behavioral approaches, and
with telephone follow-up to comprehensive management teams a focus on more intensive education in those with the greatest
comprising multiple team members. 75,86 Moreover, few have been need.
able to specify which components are most important to overall
outcome. 74 Although this is because of the system’s approach to
care uses multiple interventions, specifying primary and second- Medical Management of Care
ary goals is key to developing intervention activities. Goals for a Delivery: Protocols and Algorithms
disease management program are often to improve patient and
caregiver knowledge of the disease, enhance self-management In addition to education, one of the main objectives of disease
through skill building, increase medication and treatment adher- management programs is to ensure that patients are using pre-
ence, and improve health-related outcomes. 52,54,94,95 scribed medication regimens that optimize outcomes. Irrespective
of disease state, this may be actualized through careful dose titra-
tion of medications. Strong emphasis has also been placed on the
Education as a Part of Disease achievement of high adherence rates to prevent exacerbation of
Management symptoms or deterioration of outcomes known to impact future
risk. 57 Although national guidelines, such as those developed by
Education is a key intervention component of disease manage- the National Institutes of Health, 103,104 the American Heart As-
ment. Most often, education entails lifestyle changes including sociation, 105 and the American Diabetes Association, 106 are a
diet, exercise, and smoking cessation, as well as ways to self-mon- starting point for decisions about initiating pharmacotherapy,
itor a disease condition, including taking medication, recognizing they are often insufficient in supplying the important aspects of
important signs and symptoms, and daily monitoring of indica- dose titration necessary for disease management, especially in se-
tors such as weight, glucose, or blood pressure. The format for ed- verely ill populations such as those with heart failure. Thus, pro-
ucation differs from one program to another. Some have used tocols or algorithms that delineate appropriate dosing and that are
face-to-face individualized education, 36,43 whereas others have developed from formulary decisions of institutions are key to