Thursday, March 4, 2010

The Incremental Approach to Disease Management: Hare or Tortoise Approach?

The Disease Management Care Blog made its acquaintance today with a SGIMite (which is always a pleasure because they're really smart) internist-physician who led the creation of a Canadian regional nurse-centered disease management program. His story had an important insight about the creation of disease management/care management population-based programs.

They take time.

As the DMCB understands it, this physician approached a regional home nurse agency years ago with a proposal: dedicate a small number of nurses to a new initiative called disease management. He had a small budget that reimbursed the agency for a part of the cost of the nurses' salary and benefits. These nurses were then tasked with conducting patient outreach involving a limited number of primary care sites. The physicians were suspicious, but with time, the nurses gained acceptance. There were adjustments, but preliminary success led to additional funding in small amounts from various public and semi-private sources, which led to the hiring of additional nurses, the involvement of more physicians, with greater success which led to more funding....

While the DMCB will be finding out more details behind Calgary's Disease Management Program (it will hear a formal presentation tomorrow), the story is consistent with other successful "build your own" care management programs that the DMCB has seen: it takes years.

This approach, of course, contrasts with classic carve-out commercial care management programs, which can implement full programs in a matter of months. While that's an important strength, the DMCB wonders if gradual intrusions into a physician network in a slow one-nurse-at-a-time manner is a 'hare versus tortoise' case study. Making the countless local adjustments, achieving physician buy-in and easing in adequate funding from multiple sources may ultimately be a better approach than dropping a one-size-fits-all program on an unsuspecting physician network with a sticker-shock multi-million dollar budget. All health care is local and physicians need time to adjust.

This may account for some of the travails of some of the for-profit disease management programs with grumpy physicians and gimme-a-one-year-ROI Chief Financial Officers. It may also account for the success of the disease management programs of the large integrated delivery systems, who are in this for the long haul.

The key to physician support may come down to simply taking your time. Launching a big pre-fab disease management program isn't necessary a bad idea, especially since many of them do a good job of anticipating local practice patterns and culture. However, the Canadians are teaching the DMCB that go-slow approach may have better staying power over the long run.

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