The health care industry is looking like old Scrooge every day, between the doctors’ fees for services that don’t come with the Marcus Welby, MD bedside manner and the faster than a speeding bullet price rises in pharmaceutical drugs. The industry is looking pretty grungy and disease management is being touted as the brand new super cleaner to polish up that tarnished image. Being sold as the “warm fuzzy” of the cold, hard science of medicine, disease management (DM) programs are manned by nurses, the traditional educators in health care. Don’t you think that it is about time they packaged and marketed what has been happening to us nurses for years? I can’t remember the last time I told someone I was a nurse that they didn’t turn around and ask me a plethora of questions pertaining to their mothers, their brothers, or their own health care? This was a smart move by the health plans, pharmaceutical companies and hospitals alike to capture this guaranteed consumer audience and turn it into a cost saving program for the industry.
 
But aside from the feel good portion of the show the industry wants you to see, there is a sinister, cost saving side to why Old Scrooge is being so generous. Disease management programs also identify and stratify high cost cases by identifying risk management / high cost populations through patient profiling through the data collection process that is part of the DM process.  Since the ultimate goal of any program is to show a return on investment through the DM care interventions activities with their members, the goal for DM is cost cutting practices through patient care interventions by DM. Examples are abating  the use of emergency room visits when there is a Primary Care Physician available for office visits, or personal care practices that can be utilized when the overuse of PCP visits occurs. It is the DM philosophy that by providing the patients’ education in the best practices towards their individual medical needs they will stay healthy longer with the equally nice side effect of cutting high user costs.
 
DM is extremely helpful for a caregiver, for many times caregivers are left with questions that weren’t addressed during the hospitalization of the patient or office visit. It is often the DM nurses who find themselves fielding inquiries from both the patient and caregiver. Ideally, instruction should be given in this setting as the core issues of patient care can be met with both the subjective and objective eye for care. At times, the patient inadvertently omits key components that later prove to be barriers to providing the best practice decisions. Often it is the caregiver that fills in the pieces for the DM nurse to facilitate understanding of the education provided. In turn, DM can provide the empathic ear as well as untried care practices the caregiver can implement while providing care. DM can provide a Win-Win situation for all parties involved.
 
To understand DM and its premise, one has to have an appreciation for the adult learners. The methodology of an adult learner incorporates the value system of the individuals: if adults don’t find value in what DM is teaching, they won’t implement the health management practices we nurses will want to teach them. It is the challenge of the DM nurse to try and help individuals understand why it is important to take their medications, or go to the doctor on a regular basis. This can be an important aspect for caregivers, for at times the role of being the educator/caregiver is rejected by the very person they are caring for. That “other voice” can be invaluable in reiterating the teachings the caregiver had previously shared.
 
This takes the skill of a seasoned nurse to recognize if less or more education is needed from a call.  The magic happens in DM when goals are met during a call with the help of the DM program. Documenting this positive outcome demonstrates the success of a DM program. Initial calls take the most time, allowing for the patient’s individuality in health care and emotional needs. Once your loved one becomes an established patient, fortified with educational materials on their health care needs, the DM programs call once every two to three months to maintain the health maintenance goals. If there has been a recent hospitalization, restorative health goals are incorporated by the DM program. The nurse makes a call once a week until the individual is stable. The reevaluation of the goals every time there is an interaction with the DM nurse shows how the DM programs are interactive with the patient’s health. DM programs should be always evolving and changing around the established needs.

Both the caregiver and their loved one deserve to be exposed to the philosophy of care that disease management can provide. The health care industry is stretched thin in resources, one of which is providing the time once spent teaching patients how to care for themselves when they get home. Individuals are more clinically fragile upon discharge than they were five years ago. The discharge teaching that was once comprehensive is now whittled down to a five-minute flow sheet. Family members’ abilities to comprehend is impaired by the anxiety and desire to get home. Once home, with the adrenaline rush that sustained everyone while in the hospital gone, both the caregiver and their loved one becomes frightened by the toll of the disease condition. Too often, it is when they are home that the questions and desire to learn more become apparent.  The preventative/ restorative plans of care gently implemented with a telephonic DM program in the comfort of one’s home may be literally what the doctor ordered to stay on the right track to health.

Rose is an 18-year survivor of nursing, and is currently the CHF Disease Management nurse at University of Pittsburgh Medical Center’s Health Plan, an insurance company with over one million members, serving the greater Western Pennsylvania area.

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