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Disease management: A standardised measurement approach for assessing patient health

Anil Nayak
Wednesday, May 8, 2013, 08:00 Hrs  [IST]

There are many diseases and health problems that people deal with every day. Dealing with a chronic disease can be much harder. A portion of your time is always used in treating the disease or going to the doctor. Healthcare industry in India is providing organised cure but was lacking organised care. There is continuous gap in chronic care and lifestyle conditions, awareness, disease screening and behavioural modification. In order to control over the chronic diseases, this concept of remotely managed disease management/patient management is certainly picking up in India. This is because access to disease information and awareness is very low and rising healthcare cost.

Disease management (DM) acts as an effective tool that helps people in measuring their chronic conditions. It helps the patient in knowing their disease better by keeping a track on their health and the level of their disease. Doctors prescribe medicines to us but how well do we abide to those prescriptions? Here is where the question arises as to why a patient suffering from chronic disease has to enrol himself into a disease management programme. Many people are less updated on realms behind the effectiveness of DM services.

Even as India has earned the improbable distinction of having the highest number of chronic diseases in the world, doctors are highly advocating self-management of the disease as the best way to control it. A recent study has pointed out that 50% of people in Maharashtra alone suffer from chronic illnesses.

It is true that the numbers are so high that the doctors cannot treat all the patients on a regular basis. Even today, our appointments are booked 2-3 months in advance. That’s why patients should learn to take care of themselves and only consult doctors in emergencies as chronic diseases are lifelong disease. The management of diabetes, cardiovascular and cancer is easily done by following few self checkups in their daily life. In fact, diabetes management depends heavily on a person rather than medication. The author  of this article believes that usually patients monitor their blood sugar levels thrice a year. This is not enough and since many cannot visit the clinics frequently, we at disease management teach them to use devices so that they can home monitor their sugar levels and keep a track by way of charts and goal sheets. The most important message that DM gives is - self-help is the best help. The formula for management is simple - diet restrictions, daily exercise, regular blood sugar monitoring and insulin dosage adjustments, changing harmful personal habits like smoking and foot care like daily inspection for foot cracks, discolouration, cuts or injuries.

Monitoring your disease is a very vital aspect that will indeed shape your lifestyle ahead. At disease management we give patient education programmes in order to learn about the disease, how to manage it and the right time to consult a doctor. Thus it is indeed required for every patient to take care of himself by adhering to his/her own parameters of health because the patient itself knows his disease and body type in a right way.

DM services boost the confidence of patients. It also ensures that the patient adheres to the medication. Hence in such cases an aged individual need not have to worry about their personal care as DM services assist the patient to overcome the chances of falling ill and lower the chances of hospitalization in near future and subsequently live a healthy and normal life. Old age, ropes in various health problems like arthritis, diabetes, heart diseases, fading vision, and many more. Here complete care of patient is taken by addressing his chronic illnesses. The qualified doctors and nurses on board carry out the screening for chronic diseases among patients. Once the patient is registered with a DM programme, it provides value added services and support to the patient through various channels. It provides education literature in various languages, subsidized lab test coupons for monitoring the disease, specialty doctor consultation, SMS reminder on therapy due date, medication reminder service, phone and field based counselling to assist patient in managing disease and create awareness about the disease. Also delivery of drugs at the patients doorstep.

Disease management programmes organize care in multidisciplinary programmes with many components, using a proactive approach that focuses on the whole course of a chronic disease includes the coordination of health care, pharmaceutical or social interventions designed to improve outcomes for people and cost-effectiveness. It recognizes that a systematic approach is an optimal and cost-effective way of providing. The DM services make sure to keep the chronic disease progression in check. Also to reduce the likelihood of preventable exacerbations such as acute hospital based interventions which can be far expensive then the DM services. It offers the enticing value proposition as compliance with evidence based guidelines that the quality of health care will increase as patients improve, and that cost will decrease by eliminating unnecessary treatments and avoiding costly acute events. As health care costs have been rising for years and as per the expert predictions, the trend will continue. It is the process of reducing healthcare costs and improving quality of life. The individuals benefit from it as it prevents or minimizes the effects of a disease, usually a chronic condition, through integrative care. DM programmes are instrumental in assisting patients to handle their disease effectively and lead a normal life as far as possible. The patients, after enrolment, are offered information and education about their disease and the means to handle them through booklets/literature, regular counselling, health tips, diet books and recipes, as well as medication reminders at regular intervals with SMS alert service or a 'pill reminder machine' - a kind of alarm clock that can be set to remind the patients when it is time to take their medicines. ‘Disease advisors’, usually nurses, doctors or psychologists also assist the patients. They visit the homes of the patients to check their progress and advise them on the way forward. This, in turn, reassures the patients that they are in safe hands and would receive the required care as and when necessary. Thus, disease management system has several advantages – cutting hospital time for patients, reducing the bed patient imbalance, educating and helping the patients handle their disease effectively, assisting the doctors post diagnosis.

Disease management programmes can benefit the patient, employer and health insurance carrier. The goal for the DM is to make the patient understand his condition and ensuring he regularly visits his primary-care physician. Care premiums, which ultimately pass through to the patient/employee as well. After identifying a patient with a chronic condition, a clinical care manager attempts to speak with the patient to assess his/her condition. This assessment traditionally occurs by telephone but may also occur face-to-face. The assessment is a series of questions about the patient's current condition; lifestyle and behavioural actions to determine his/her risk level. Based on the assessment answers, the care manager develops, in conjunction with the patient, a care plan for the patient to follow. The care manager from DM and patient will have ongoing meetings with frequency determined by risk level the more high-risk the patient, the more frequent the discussions. At these sessions, the goal is to educate the patient and improve his health and lifestyle. Non adherence to medication is a major impact for poor therapy outcomes and treatment for chronic disease.

(Author is managing director of Kartavya Healtheon


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