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C HAPTER 4 2 / Disease Management Models for Cardiovascular Care 929
frequency of contact, the context for what is provided to patients, A final important challenge facing disease management relates
and whether patients are followed-up for 1 month, 1 year, or in- to the transitional aspects of care and the health care delivery sys-
definitely. To date, few programs have analyzed the most impor- tem. Acute care that has been linked to the hospital must truly be
tant components of their programs, and few have compared the linked to the delivery of chronic care. A problem confronting
effectiveness of different programs or the individual components some patients has been the perceived loss of control over the
or combinations of components within programs. 125 It is likely health care system. 129 Nelson found that impersonal service,
that those who demonstrate high accountability through good pa- health care system navigation, and, for many, feeling discounted
tient outcomes at a reasonable cost and that also offset the high by the medical care system are problems many older adults patient
costs of acute exacerbations will likely prevail. Finally, web-based face today. Conversely, feeling cared for and receiving support
technology now affords the opportunity for health care profes- were frequently cited by those patients participating in nurse case
sionals to follow-up patients over an extended period of time. management. Structured appropriately, disease management
Does home telemonitoring for chronic disease improve patient models must help to support a successful transition from home to
outcomes? The use of electronic blood pressure monitors, blood hospital and other settings. Ensuring a smooth transition with the
glucose meters, and voice recognition technology offers data that disease manager operating in partnership with the patient at the
can be concealed during infrequent office visits. A Cochrane Re- center is likely to reduce the sense of loss of control for patients
view evaluated the use of home telemonitoring on improvement and families. More opportunities will arise to improve care as
of patient outcomes. 126 Their review suggests that irrespective of communication technologies improve and our capability to mon-
nationality, socioeconomic status, or age, patients are relatively itor patients in the home environment is extended.
adherent with telemonitoring programs and technologies. Studies In summary, disease management models offer the promise of
in patients with cardiological problems showed significant benefit better care for millions of individuals with multiple risk factors and
on clinical outcomes from the use of such devices. However, re- known cardiovascular diseases. Although much has been studied,
search is still needed on the cost-effectiveness of the use of these the challenge of implementation of those models showing improved
technologies, the impact on service utilization, and the acceptance outcomes must continue, and further research is needed about best
by health care professionals such as case managers. methods for dissemination. Much of this challenge rests in the
Although disease management models have been effectively hands of nurses who participate in research in disease management
implemented in research and clinical practice, it is likely that such and those who are in newly defined disease management roles.
programs will be delivered only to subgroups of patients in the fu-
ture, because of cost. Peer support models for self-management of
chronic conditions have also been tested. 127,128 These offer signif- REFE R E NC ES
icant promise as an alternative modality supporting self-manage-
ment of symptoms in individuals with chronic conditions. The 1. Lazarus, A. (2001). The promise of disease management. Psychiatric
Services, 52, 161–171.
2
2
Chronic Disease Management Program is a community-based, 2. National Center for Health Statistics. (1999). Health, United States 1999.
peer-led program designed to help those individuals with chronic Hyattsville, MD: U.S. Government Printing Office.
conditions such as cardiovascular disease, arthritis, pulmonary dis- 3. Centers for Disease Control. National Center for Health Statistics.
5
5
ease, and stroke. This program, which is offered to 10 to 15 par- (2006). Deaths. Preliminary data for 2005. Retrieved June 5, 2008, from
www.nlm.nih.gov/medlineplus/healthstatistics.html.
ticipants over 7 weeks in 2.5-hour group sessions and led by a 4. The Robert Wood Johnson Foundation. (2000). Health and healthcare
trained peer leader, focuses on improving self-management skills 2010: The forecast, the challenge. Princeton, NJ: The Robert Wood Johnson
e
e
based on self-efficacy theory, drawing on peers for support. Foundation.
Weekly sessions focus on action planning and feedback, modeling 5. The Robert Wood Johnson and Johns Hopkins University Partnerships
e
e
of behaviors and problem solving by participants for one another, for Solutions. (2002). Chronic conditions: Making the case for ongoing care.
Princeton, NJ: The Robert Wood Johnson Foundation.
group problem solving, and individual decision making. Sup- 6. Smith, B., Forner, E., Zaslow, B., et al. (2005). Disease management
ported by a program guide entitled “Living a Healthy Life with produces limited quality of life improvements in patients with congestive
Chronic Conditions,” weekly content includes the following: heart failure: Evidence from a randomized controlled trial in community-
adopting exercise programs; use of cognitive symptom manage- dwelling patients. American Journal of Managed Care, 11, 701–713.
ment techniques, such as guided relaxation and distraction; fa- 7. Goetzel, R., Ozimkowski, R., Villagra, V., et al. (2005). Return on investment
6
in disease management: A review. Health Care Financing Review, 26 1–19.
6
tigue and sleep management; use of medications and community 8. Berra, K. B., Houston Miller, N., Fair, J. (2006). Cardiovascular disease
resources; managing the emotions of fear, anger, and depression; prevention and disease management. Journal of Cardiopulmonary Reha-
6
6
training in communication with health care professionals and bilitation, 26, 197–206.
others; health-related problem solving; and decision making. 9. Wagner, E. H., Austin, B., & Von Korff, M. (1996). Organizing care for
4
4
patients with chronic illness. Milbank Quarterly, 74(4), 511–542.
In a study of 831 subjects, Lorig et al. 127 found that compared 10. Miller, N. H., Hill, M. N., Kottke, T., et al. (1997). The multilevel com-
with baseline, for each of 2 years, emergency department and out- pliance challenge: Recommendations for a call to action. A statement for
patient visits were reduced (p .05) and self-efficacy improved in healthcare professionals. Circulation, 95, 1085–1990.
5
5
those attending the sessions (p .05). This model, now widely 11. Unger, B. T., & Warren, D. A. (1999). Case management in cardiac re-
used by health care organizations in the United States and abroad, habilitation. In N. K. Wenger, L. K. Smith, E. S. Froelicher, et al. (Eds.),
Cardiac rehabilitation: A guide to practice in the 21st century (pp.
offers another important alternative for disease management. The 327–341). New York: Marcel Dekker.
question remains whether the high cost of training the peer teach- 12. Ellrodt, G., Cook, D. J., Lee, J., et al. (1997). Evidence-based disease
8
ers who frequently are unavailable after their initial orientation management. JAMA, 278, 1687–1692.
versus investing in nursing professionals who can and will sustain 13. Disease Management Association of America. (2008). The definition of
t
t
such programs remains to be seen. Also, in persons with multiple disease management. Retrieved June 13, 2008, from http://www.dmaa.
org/definition.html.
chronic conditions, the extent to which a peer education program 14. Krumholz, H. M., Riegel, B., Phillips, C. O., et al. (2006). A taxonomy
is safe has also not been addressed. for disease management: A scientific statement from the American Heart