Chronic disease management programs

Chronic disease management (CDM) programs are proactive, organized sets of interventions focused on the needs of a defined population of patients. Program design varies, but CDM programs are usually multi-component efforts that include planned visits to teach patients about their disease, coach them on healthy behavior change including medication adherence, and skills for self-management of chronic conditions in partnership with a coordinated, multidisciplinary care team. Interventions may be based on the Chronic Care Model, which identifies links to community resources, health system support, health care system redesign, self management and provider decision support, and the use of clinical information systems as essential elements for health care systems to support high quality chronic disease care. CDM programs can support patients with illnesses such as diabetes, hypertension, heart failure, and depression, and can be delivered in various health care settings (CCM). 

Expected Beneficial Outcomes (Rated)

  • Improved quality of life

  • Improved health outcomes

  • Improved mental health

  • Reduced hospital utilization

Evidence of Effectiveness

There is strong evidence that chronic disease management (CDM) programs improve quality of life (Cochrane-Kruis 2013*, Cochrane-Peytremann-Bridevaux 2015*, Miller 2013b, Cochrane-Archer 2012*, Drewes 2012) and health outcomes for a variety of chronic conditions (Baptista 2016, Cochrane-Peytremann-Bridevaux 2015*, CG-CVD, Cochrane-Kruis 2013*, Stellefson 2013b, Cochrane-Archer 2012*, Woltmann 2012*, Drewes 2012, Pimouguet 2011, Si 2008*, CG-Diabetes), including mental illness (Cochrane-Archer 2012*, Woltmann 2012*). CDM programs have also been shown to reduce hospital admissions for COPD (Cochrane-Kruis 2013*) and hospitalizations and mortality for heart failure patients (Drewes 2012).

Chronic disease management programs, and the Chronic Care Model specifically, have been shown to improve health outcomes in patients with diabetes (Stellefson 2013b, Pimouguet 2011, Si 2008*, CG-Diabetes), heart failure (Drewes 2012), hypertension (CG-CVD), COPD (Cochrane-Kruis 2013*, Peytremann-Bridevaux 2008*), and anxiety and depression (Cochrane-Archer 2012*, Woltmann 2012*). In some cases, such interventions also improve outcomes for patients with asthma (Cochrane-Peytremann-Bridevaux 2015*), osteoarthrosis (Brand 2014*), and HIV (Pasricha 2013). Studies of CDM for patients with diabetes, asthma, and COPD indicate that using multiple components of the Chronic Care Model may increase program effectiveness (Baptista 2016, Lemmens 2009).

CDM improves quality of life for patients with asthma (Cochrane-Peytremann-Bridevaux 2015*), COPD (Cochrane-Kruis 2013*, Peytremann-Bridevaux 2008*), heart failure (Drewes 2012), and mental health issues (Woltmann 2012*). CDM may be more effective for patients with more severe mental illness than for those with less severe symptoms (Miller 2013b).

Disease management interventions for patients with multiple chronic diseases may improve some health outcomes but additional evidence is needed to confirm effects (Cochrane-Smith 2016*, Bleich 2015).

Impact on Disparities

No impact on disparities likely

Implementation Examples

There are many types of CDM programs. Middlesex Hospital in Middletown Connecticut’s program is an example of a hospital-based outpatient effort that serves the sickest patients with asthma, heart failure, and diabetes (AHRQ HCIE-Mansfield). The Sutter Care Coordination Program in the Sacramento Sierra region, which combines chronic care and disease management to address the medical and psychosocial needs of patients with multiple chronic conditions, is another example (AHRQ HCIE-Van der Mei).

As of January 2015, Medicare covers non-face-to-face chronic care management for patients with multiple chronic conditions who are at significant risk of death, acute exacerbation/decomposition, or functional decline (CMS-CCMS).

Implementation Resources

IHI-CCM - Institute for Healthcare Improvement (IHI). Chronic care management (CCM).

Moore 2015 - Moore K, Hays B. Answers to your questions about chronic care management. Family Practice Management. 2015;22(3).

Fromer 2011 - Fromer L. Implementing chronic care for COPD: Planned visits, care coordination, and patient empowerment for improved outcomes. International Journal of COPD. 2011;6:605–614.

Citations - Evidence

* Journal subscription may be required for access.

Cochrane-Kruis 2013* - Kruis AL, Smidt N, Assendelft WJ, et al. Integrated disease management interventions for patients with chronic obstructive pulmonary disease (Review). Cochrane Database of Systematic Reviews. 2013;(10):CD009437.

Cochrane-Peytremann-Bridevaux 2015* - Peytremann-Bridevaux I, Arditi C, Gex G, Bridevaux PO, Burnand B. Chronic disease management programmes for adults with asthma (Review). Cochrane Database of Systematic Reviews. 2015;(5):CD007988.

Miller 2013b - Miller CJ, Grogan-Kaylor A, Perron BE, et al. Collaborative chronic care models for mental health conditions: Cumulative meta-analysis and meta-regression to guide future research and implementation. Medical Care. 2013;51(10):922–930.

Cochrane-Archer 2012* - Archer J, Bower P, Gilbody S, et al. Collaborative care for depression and anxiety problems (Review). Cochrane Database of Systematic Reviews. 2012;(10):CD006525.

Drewes 2012 - Drewes HW, Steuten LMG, Lemmens LC, et al. The effectiveness of chronic care management for heart failure: Meta-regression analyses to explain the heterogeneity in outcomes. Health Services Research. 2012;47(5):1926–1959.

Baptista 2016 - Baptista DR, Wiens A, Pontarolo R, et al. The chronic care model for type 2 diabetes: A systematic review. Diabetology & Metabolic Syndrome. 2016;8(1):1–7.

CG-CVD - The Guide to Community Preventive Services (The Community Guide). Cardiovascular disease (CVD).

Stellefson 2013b - Stellefson M, Dipnarine K, Stopka C. The chronic care model and diabetes management in US primary care settings: A systematic review. Preventing Chronic Disease. 2013;10:120180.

Woltmann 2012* - Woltmann E, Grogan-Kaylor A, Perron B, et al. Comparative effectiveness of collaborative chronic care models for mental health conditions across primary, specialty, and behavioral health care settings: Systematic review and meta-analysis. American Journal of Psychiatry. 2012;169(8):790–804.

Pimouguet 2011 - Pimouguet C, Le Goff M, Thiébaut R, Dartigues JF, Helmer C. Effectiveness of disease-management programs for improving diabetes care: A meta-analysis. Canadian Medical Association Journal. 2011;183(2):E115–E127.

Si 2008* - Si D, Bailie R, Weeramanthri T. Effectiveness of chronic care model-oriented interventions to improve quality of diabetes care: A systematic review. Primary Health Care Research & Development. 2008;9(01):25–40.

CG-Diabetes - The Guide to Community Preventive Services (The Community Guide). Diabetes.

Peytremann-Bridevaux 2008* - Peytremann-Bridevaux I, Staeger P, Bridevaux PO, Ghali WA, Burnand B. Effectiveness of chronic obstructive pulmonary disease-management programs: Systematic review and meta-analysis. The American Journal of Medicine. 2008;121(5):433–443.e4.

Brand 2014* - Brand CA, Ackerman IN, Tropea J. Chronic disease management: Improving care for people with osteoarthritis. Best Practice & Research Clinical Rheumatology. 2014;28(1):119-142.

Pasricha 2013 - Pasricha A, Deinstadt RTM, Moher D, et al. Chronic care model decision support and clinical information systems interventions for people living with HIV: A systematic review. Journal of General Internal Medicine. 2013;28(1):127–135.

Lemmens 2009 - Lemmens KMM, Nieboer AP, Huijsman R. A systematic review of integrated use of disease-management interventions in asthma and COPD. Respiratory Medicine. 2009;103(5):670–691.

Cochrane-Smith 2016* - Smith SM, Wallace E, O’Dowd T, Fortin M. Interventions for improving outcomes in patients with multimorbidity in primary care and community settings (Review). Cochrane Database of Systematic Reviews. 2016;(3):CD006560.

Bleich 2015 - Bleich SN, Sherrod C, Chiang A, et al. Systematic review of programs treating high-need and high-cost people with multiple chronic diseases or disabilities in the United States, 2008–2014. Preventing Chronic Disease. 2015;12:150275.

Citations - Implementation Examples

* Journal subscription may be required for access.

AHRQ HCIE-Mansfield - Mansfield, V. Disease management programs improve adherence to evidence-based processes and outcomes by targeting sickest patients and working closely with physicians. Rockville: AHRQ Health Care Innovations Exchange.

AHRQ HCIE-Van der Mei - Van der Mei, J. Chronic care and disease management improves health, reduces costs for patients with multiple chronic conditions in an integrated health system. Rockville: AHRQ Health Care Innovations Exchange (HCIE).

CMS-CCMS - Centers for Medicare & Medicaid Services (CMS), Medicare Learning Network (MLN). Chronic care management services (CCMS). US Department of Health and Human Services (US DHHS); 2015.

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