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926 PA R T V / Health Promotion and Disease Prevention
managing medications effectively in disease management pro- most health care settings has yet to be realized. In some instances,
grams. Nurses have played important roles in the management of the disease management program is situated outside the usual
the pharmacological aspects of disease management. Many State health care delivery system that the patient is enrolled in, or a
Nurse Practice Acts require that nurses follow strict protocols for database for disease management is separate from the existing
managing medications in an outpatient setting that must be up- paper-based or electronic medical record. Thus, to facilitate clear
dated annually. 107 Moreover, the development of protocols for communication about ongoing management, letters updating
medication management is often a shared responsibility of nurses, physicians and documentation of care within the medical record
physicians, and pharmacists within the local institution offering become crucial. These can be facilitated through computer-gener-
the disease management program. Advanced Practice Nurses are ated reports highlighting clinical progress to physicians and the
in an excellent position to help manage the pharmacologic aspects development of standard tools for receiving responses from physi-
of disease management and have often taken on this role as case cians. The frequency of phone-based interactions and the format
managers. for receiving information about the care being delivered to pa-
tients as part of disease management should be addressed as part
of the development of algorithms and protocols. Interactions with
Structuring Interventions: The physicians most often relate changes in symptoms and medica-
Process of Coordinating Care tions and need to be addressed by the team. Physician champions
who can facilitate problem solving and offer expertise to nurses in
Interventions that focus on education and medication manage- the absence of primary care or specialty physicians facilitates suc-
ment as part of any disease management program must be struc- cess with program implementation.
tured in a way to optimize outcomes. As previously mentioned, Anticipating the needs of patients and family members, nurses
there is large variation in the frequency of interactions with pa- also plays a role in coordinating the care delivered by other health
tients, the use of face-to-face visits versus telephone follow-up, care professionals such as social workers, pharmacists, dietitians,
how much follow-up is needed, whether in-home monitoring can and psychologists. These disciplines offer specialized expertise in
support health care professionals and the number of health care defined fields often required for managing long-term chronic con-
professionals including the expertise of nurses required for disease ditions. Overseeing the presence of social isolation and depression
management. However, several investigators suggest that the most is very important. The need for economic and material support,
important factors to be addressed in making decisions about how and continued education related to diet and medications, is nec-
to structure the frequency of interactions to the following: (1) un- essary for improvement of patient outcomes such as reduction in
derstanding the needs of the patient population based on prob- utilization.
lems (e.g., lack of adherence, material support, frequent hospital-
izations, inadequate risk factor control); (2) deciding whether
face-to-face, group, or individual interventions will enhance over-
all success, or whether telephone or electronic encounters are suf- Measuring Clinical and Resource
ficient to enhance motivation; (3) determining if home visits are Utilization Outcomes
needed; (4) noting what the time-frame is for problematic behav- Irrespective of a research or clinical initiative in disease manage-
iors and lack of adherence; and (5) considering how much tailor- ment, collecting data on outcomes is crucial to evaluating a pro-
ing is needed to support individual patients. Irrespective of gram. Many disease management programs collect process and
whether face-to-face interventions or telephone or electronic en- outcome data including resource utilization, quality of life, pa-
counters are used, most often interactions occur more frequently tient satisfaction, 111 physician satisfaction, and program costs,
in the early phases of disease management programs and are de- which is important to substantiate the need for these programs.
signed to taper-off as patients and family members learn how to Health insurance companies and payers of care are most interested
better self-manage behaviors and pharmacotherapies. Many in outcomes associated with a reduction in emergency department
groups have successfully operationalized disease management in visits, in hospitalizations or rehospitalizations, length of hospital
research settings through several studies 33,49,52–54,67–69,91,97,108 stay, and costs of care. This type of information is obtained from
and offer their experience, whereas others who have had success in financial records or review of medical records and insurance in-
clinical practice settings for more than 10 years 11,72,109,110 offer formation. Keeping accurate process data in an individual data-
important perspectives on the structuring of interventions and the base that is part of the disease management program assists in de-
coordination of care delivery.
termining whether adequate pharmacologic treatment was
delivered, thus ultimately influencing outcomes.
Communication With Physicians Quality of life is most often measured within the research set-
and Other Personnel ting. However, patients and family members place high value on the
improvement of quality of life as an outcome of disease manage-
The frequency of interactions with other personnel in the disease ment programs. Thus, measurement of this outcome is important
management team is important to overall care. One of the failures in clinically based programs. Although researchers have difficulty
of the current system in the United States in managing those with agreeing on what constitutes overall quality of life, comprehensive
chronic conditions has been the frequency of visits to multiple tools exist to measure many of the important components includ-
physician providers and the lack of communication among them. ing biologic or physiologic indicators, symptoms, functioning,
In disease management models, nurses most often assume the role health perceptions, and overall well being. Some of the most com-
of coordinating care between two or more providers. Electronic monly used tools include the MOS Short Form-36 Item Question-
medical records within large systems have often facilitated that naire (SF-36) 112,113 and the Sickness Impact Profile. 94,114 Shorter
88
communication. However, full integration of these systems in tools such as the Short-Form 12, a modification of the SF-36, are