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Managing Care for Adults with Chronic Conditions

Identifying & Managing Chronic Conditions

The least intensive strategies for managing care for adults with chronic conditions involve the early identification and management of a condition. These strategies typically include:

  • Identifying individuals at risk of developing a chronic condition.
  • Helping to prevent the occurrence of chronic conditions.
  • Promoting chronic disease self-management through education.
  • Using technology to manage chronic conditions.
  • Implementing disease management programs.

These strategies can offer States opportunities to improve care for people with chronic conditions. Examples include:

  • The Chronic Disease Self-Management Program, funded by the Agency for Healthcare Research and Quality (AHRQ) and conducted by the Stanford Patient Education Research Center, trains local leaders to educate people with chronic conditions about their health needs. The model coaches the patient to build his or her confidence to perform three tasks: disease, role, and emotional management. Its train-the-trainer approach involves multiple components (management of fatigue, pain, and isolation; exercise; communication; nutrition; and evaluating new treatments). Several States (Washington, Oregon, Nevada, Texas, and Indiana) have used this model to implement a diabetes program. The Washington diabetes collaborative is in its third phase.

    The program achieved statistically significant improvements in health behavior, health status, and health care utilization and self-efficacy in one year. Participants averaged 0.8 fewer days in hospital, and there was a trend toward fewer outpatient visits. The estimated cost of the intervention is $100 to $200 per patient.

  • Studies have shown that telemedicine using computer assisted care systems can effectively monitor some patients' health status, increase adherence to treatment plans, and improve some health outcomes.

    For example, the Interactive Voice Response (IRV), developed with funding from AHRQ, is an automated telephone system that contacts people with diabetes each week and measures glycemic control, self-care, health related quality of life, and satisfaction with care. IVR is most successful at administrative remedies (reminders) and only works with live followup. The program costs are most significant during the start-up of the initiative. Once the program is operating, the cost of adding additional patients is nominal.

  • The Health Buddy program uses a computer module to obtain daily feedback on patients' symptoms, behavior, and knowledge. This information allows for close monitoring of the patient's health status. The system served 435 Veterans Administration patients and generated savings of $2 million over a two-year period.

    Case managers, with an average case load of 150 patients, monitor Health Buddy responses daily and are required to have contact with the patient at least once every 90 days. Among veterans participating in the program for a year or more, hospitalizations decreased 46 percent, primary care/emergency department visits declined 19 percent, and bed days of care declined 29 percent.

  • The Florida Medicaid Disease Management program offers beneficiaries with specific conditions the opportunity to enroll in a program to improve self-management. Currently, the State's Agency for Health Care Administration operates diabetes, asthma, congestive heart failure, hypertension, diabetes, and depression programs. These are public-private partnerships between the State and several prescription drug companies. The contracts between the two entities include guaranteed savings for the State.

  • The Asheville Project operated by the City of Asheville, North Carolina, pays pharmacists to provide counseling services to City employees who have diabetes, asthma, or hypertension. The project provides 32 hours of training for pharmacists and includes a fee schedule that compensates pharmacists after results are achieved. Incentives are used to encourage enrollment and compliance and include waiving pharmacy and lab co-payments and providing free glucose meters that track blood sugar for 30 days. The use of these meters allows pharmacists to intervene early and call the provider to change medications as needed.

    The program has reduced employee absenteeism and City health care costs. Use of angiotensin converting enzyme (ACE) inhibitors by diabetics, one indicator of appropriate medication use went from zero percent prior to the program to 33 percent after 14 months in the program and 57 percent after 24 months. North Carolina has also started programs for asthma, hypertension, and lipids.


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