Vol. 2 Issue 8
Disease Management: A New Role in Nursing
Nurses can engage and encourage patients to maintain a more active role in their health care
Disease management is not the management of a disease state, but rather a holistic approach to providing health care services and benefits to a person or population that exhibits certain "conditions." It involves a coordination and integration of systems to provide a comprehensive approach to health care delivery.
Disease management encompasses the clinical, economical and psychosocial aspects of providing health care and entails a certain amount of proactive, preventative services. Disease management seeks to influence or encourage the modification of the health-related behaviors of patients, providers and purchasers to reduce the occurrence and severity of certain disease states or conditions. Any health care behavior modification is substantiated and supported by a continuous improvement process, which provides for constant feedback and is based upon specific medical conditions and appropriate population processes and outcomes.
Disease management programs not only pursue the optimal clinical outcome, but also the most cost-effective outcome for a specified patient population. There are three main components to any disease management program: 1) a knowledge base regarding the natural and probable financial history of the medical condition; 2) the health care delivery system; and 3) a continuous improvement process that has the ability to both measure and evaluate outcomes.
Disease management is a population-based method to providing health care that utilizes the concept of self-care. A basic tenet of disease management is that the patient will provide 95 percent of chronic illness care to himself. The patient must assume the ultimate responsibility for his own care and the healthstyle and lifestyle choices he selects. This responsibility is his 24 hours per day, 7 days per week; and, while it is nontransferable, it may be shared.
However, disease management assumes that without a sufficient knowledge and skill base, especially in health promotion and disease prevention, the care the patient provides for himself will be neither the best nor the most desirable.
Disease management programs are not simply intervention management programs. Patient education tools do contribute significantly to the overall success of any disease management program. Patient participation and compliance with program efforts are critical for effective disease management. Therefore, although patient selection into a disease management program is usually very broad-based, the interventions of the program are very tailored and are established by the severity of the illness, an assessment of the patient's current self-management skills and his readiness for change.
The underlying assumptions of disease management programs are that: 1) an informed patient is better equipped to help manage his condition than an uninformed one; 2) the patient is the ultimate consumer of health care services and will demand satisfactory management of his medical condition; and 3) patients have a profound effect on their clinical outcomes and should therefore understand their responsibility in managing their own health.
Also, patient education components not only serve to educate the patients and their families, but also to encourage patient self-management and to facilitate the involvement of patients and their families as active participants in their health care. Educational material and treatment guidelines should be either readily available or able to be easily developed.
Evidence-based protocols and treatment guidelines are extremely important in ensuring that all members of the health care infrastructure are consistent in their interactions and interventions with the disease management patients. Consistency helps to decrease practice variation and to minimize confusion. On the other hand, guidelines must be flexible enough to respect individual styles of practice, but not flexible enough to encourage variation from practice to practice.
WHAT NURSES BRING
The skills and functions of nurses who serve as disease management coordinators may be found in a variety of settings including hospitals, third-party payers (insurance companies), for-profit health management companies, doctor's offices and outpatient clinics.
The educational background that most nurses possess allows them to effectively transition into this field. Nursing programs teach illness prevention, health promotion and behavioral change strategies within the curriculum. Nursing programs also establish an understanding of the natural history of illnesses and disease processes, and introduce students to the various health care delivery systems such as inpatient, outpatient and community-based programs.
The American Nurses Association (ANA) considers the management of chronic conditions to be a fundamental nursing role with nurses integrating, coordinating and advocating for individuals who may require extensive services (ANA, 1992). Furthermore, nurses are comfortable in conducting and interpreting research on health care outcomes, are involved on the forefront of the revolution in information technology that has been transforming the delivery of health care, and have embraced the use of evidence-based practice.
Nurses' credentials have enabled them to have a firm understanding of and the ability to effectively communicate about many of the conditions that routinely send people into the hospital. Moreover, nurses have the capability of evaluating the patient's readiness to change and to use an appropriately timed and type of coping mechanism in order to set this change process into motion.
The foremost role of the nurse in disease management is to act as a change agent. The current emphasis of delivering health care to those who seek it on an individual basis needs to be switched instead to a focus of engaging chronic illnesses from a population-based perspective. Escalating health care costs could be reversed by assuring the adherence to evidenced-based clinical practice guidelines, ascertaining that various patient populations are receiving the recommended clinical follow-up and diagnostic examinations in a timely manner, and ensuring that these populations continue to take prescribed pharmaceuticals over an extended period of time.
Nurses need to educate both patients and other health care providers on understanding behavioral change techniques and their application. Patients should be engaged and encouraged to maintain a more active role in the delivery of their health care. Interventions should be focused on empowering the patient and fostering independence from, rather than dependence on, the health care system.
Even with the latest advances in medicine and pharmacology, chronic illnesses can often be prevented or partially controlled with modest lifestyle modifications. Moreover, small successes must be routinely and continually celebrated. A success is not just if the patient stops smoking a success is also if the patient decreases from two packs of cigarettes a day to one pack or even if he goes from not thinking about stopping smoking to considering it.
A COMPATIBLE MATCH
Disease management is a relatively new field for nurses, one that benefits from their existing knowledge and expertise. Disease management approaches health management as a hybrid of case management/utilization review and health promotion/illness prevention. The ultimate goal is to improve the health status of a patient population and, ideally, to reduce health care costs by focusing on those patients who have chronic diseases or moderate-to-severe acute illnesses and that are responsible for the middle third of health care costs.
Disease management nurses also serve as patient advocates, acknowledging not only their rights, but also their responsibilities. The backgrounds of disease management and nursing make for a very compatible match.
American Nurses Association. (1992). Nursing's agenda for health care reform. Washington, DC: Author.
James Blackwell is disease management coordinator with Blue Cross and Blue Shield of South Carolina. The views expressed in this article are those of the author and do not necessarily reflect the views of Blue Cross and Blue Shield of South Carolina or any of its subsidiaries.