TRICARE currently provides disease and chronic care management activities for
asthma, diabetes, heart failure, chronic obstructive pulmonary disease (COPD),
depression, and anxiety for its beneficiaries that meet the programs
eligibility criteria, in all three regions. Plans to implement cancer
screening are slated for FY 2011. As health care delivery systems evolve,
TRICARE continuously looks at ways to improve and enhance its chronic care
management model to provide the most clinically and cost effective programs to
Historically, disease management has been defined as:
- A system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant.
- An organized effort to achieve desired health outcomes in populations with prevalent, often chronic diseases, for which care practices may be subject to considerable variation.
Changing trends in healthcare are driving the adaptation of disease management to a more integrated approach, demanding value supported by measurable outcomes, while remaining flexible to new opportunities for innovation and evolving dynamics.
In this spirit, The Care Continuum Alliance (formerly the Disease Management Association of America – DMAA) has recognized the need for a broader definition, and has updated their name as well as its approach that promotes a proactive, accountable, patient-centric population health improvement model featuring a physician-guided health care delivery system designed to develop and engage informed and activated patients over time to address both illness and long term health.
Key components of the population health improvement model include:.
- Population identification strategies and processes;
- Comprehensive needs assessments that assess physical, psychological, economic, and environmental needs;
- Proactive health promotion programs that increase awareness of the health risks associated with certain personal behaviors and lifestyles;
- Patient-centric health management goals and education which may include primary prevention, behavior modification programs, and support for concordance between the patient and the primary care provider;
- Self-management interventions aimed at influencing the targeted population to make behavioral changes;
- Routine reporting and feedback loops which may include communications with patient, physicians, health plan and ancillary providers;
- Evaluation of clinical, humanistic, and economic outcomes on an ongoing basis with the goal of improving overall population health.
For a list of DM resources and additional reading, click here.