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Evidence-Based Disability and Disease Prevention for Elders

Replicating Chronic Disease Management


Melanie Bella, M.B.A., Director, Office of Medicaid Policy and Planning, Indiana Family and Social Services Administration, Indianapolis, IN.

The Indiana Chronic Disease Management Program (ICDMP), is a disease management program developed through a partnership between the State Medicaid program and the Department of Public Health for persons with diabetes, asthma, congestive heart failure, and hypertension, and for others who are at high risk of chronic disease.

The goal of the ICDMP is to build a comprehensive, locally based infrastructure that is sustainable and that will strengthen the existing public health infrastructure and help improve the quality of health care in all populations. The program uses the Chronic Care Model to achieve its goals.

The first objective of ICDMP is to provide consistently high quality care to Medicaid beneficiaries that improves health status, and enhances quality of life. Secondly, the program seeks to reduce the overall cost of providing health care to Medicaid beneficiaries with chronic diseases. Finally, it is designed to achieve long-term results by changing the way primary care is delivered for all citizens across the State.

The program provides support to primary care providers, integrates primary care with case management, teaches participants self-management skills, and utilizes and strengthens the public health infrastructure.

How Can States Best Approach Disease Management?

States can either "make, buy, or assemble" disease management programs.

To make a program, states develop it "in house," typically as part of a primary care case management (PCCM) program. This allows for and takes advantage of local input and experience and focuses on the provider/patient relationship. Such an approach keeps revenues and jobs in-state and creates a comprehensive, sustainable, locally based infrastructure with effective case management in place to support primary care providers and Medicaid members. It requires significant State resources and the State retains the financial risk.

States can buy a complete program from a commercial vendor and purchase a chronic illness software system. This approach offers "guaranteed" savings through a contract with a vendor; however, it is difficult to negotiate risk for a Medicaid population, and jobs and revenue associated with running the program typically go out of state. The focus tends to be on telephonic case management and allows for little or no local input/experience. Finally, commercial programs often conflict with the state's Medicaid claims systems and require duplicative reporting.

Indiana chose a third, hybrid approach: it assembled a program. The State has purchased key components but retains control of the program.

What Are the Main Components of the ICDMP?

Indiana chose this approach because it had dedicated local partners interested in changing the way care is delivered statewide. Indiana was attracted to the Chronic Care Model developed by Dr. Edward Wagner and a team of national experts at the MacColl Institute, Institute for Healthcare Improvement.

The Chronic Care Model uses evidence based interventions with proven results, promotes patient self management, and carries over to improve care for all patients in a practice.

The main components of the ICDMP include:

  • Program management: Medicaid and Health are jointly responsible for program management including policy development, contracting, and performance monitoring.
  • Primary care: The focal point of patient care is the primary care physician. Key elements of the Indiana CDM program are designed to provide information and resources to support the physician, including dissemination of evidence-based guidelines.
  • Case management: Care management is comprised of a call center that monitors patient status and followup based on the established protocols and a nurse care manager network whose nurses provide more intense follow up and support to high risk patients.
  • A patient data registry: An electronic data registry is available to physicians and can be used for all patients. For Medicaid patients, the data registry is populated with claims data and case management data.
  • Measurement and evaluation: Measures of program performance are being established using both claims history data and individual health outcomes indicators for both an intervention and control group. Program implementation was phased in across regions and diseases. The program currently focuses on diabetes, congestive heart failure, and asthma.

A community based infrastructure is key to the model. The goal is to solidify the relationship between the patient and the medical home by providing supports to those two key partners through self management training. Supports to providers come from chronic care model collaborative training. Participants must learn how to measure and report and use a feedback loop so that practice redesign that doesn't disrupt the operation of the practice.

What Are ICDMP's Accomplishments to Date?

The program showed significant reductions in three chronic disease markers in the first year, Hemoglobin A1c, self management goals, and a blood pressure of < 130/80. The first phase of the program included a randomized trial and a statewide evaluation. Evidence based guidelines have been agreed to by all payors in Indiana. Phase 2 will concentrate on performance measures, while Phase 3 will concentrate on the data.

Are There New Developments in the Future for ICDMP?

Once an infrastructure and supports are in place, new developments and additional programs can be incorporated into the program. Indiana's program will be expanded to include three new disease states: hypertension, stroke, and HIV/AIDS. Implementation will include ongoing refresher courses for eligible members and analysis of additional stratification elements to identify potential high risk members before they become high risk. Indiana plans to increase the spread of the program to more providers as well as to commercial payers, Medicare, employers, and State employees

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