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Population Health

Care Continuum Alliance (CCA) Definition of Disease Management

Disease management is a system of coordinated health care interventions and communications for populations with conditions in which patient self-care efforts are significant.

Disease management:

  • Supports the physician or practitioner/patient relationship and plan of care;
  • Emphasizes prevention of exacerbations and complications utilizing evidence-based practice guidelines and patient empowerment strategies; and
  • Evaluates clinical, humanistic, and economic outcomes on an on-going basis with the goal of improving overall health.

Disease management components include: *

  • Population identification processes;
  • Evidence-based practice guidelines;
  • Collaborative practice models to include physician and support-service providers;
  • Patient self-management education (may include primary prevention, behavior modification programs, and compliance/surveillance);
  • Process and outcomes measurement, evaluation, and management;
  • Routine reporting/feedback loop (may include communication with patient, physician, health plan and ancillary providers, and practice profiling).

* Note: Full-service disease management programs must include all six components. Programs consisting of fewer components are disease management support services.

Notes from the CCA Dictionary of Disease Management Terminology

Traditionally, disease management has focused on the "big five" chronic diseases: ischemic heart disease, diabetes, COPD, asthma and heart failure. Disease management programs generally are offered telephonically, involving interaction with a trained nursing professional, and require an extended series of interactions, including a strong educational element. Patients are expected to play an active role in managing their diseases.

Because of the presence of co-morbidities or multiple conditions in most high-risk patients, this approach may become operationally difficult to execute, with patients being cared for by more than one program. Over time, the industry has moved more toward a whole person model in which all the diseases a patient has are managed by a single disease management program.

Provider Contracting Toolkit

Provider Contracting Toolkit - ViewThe American Association of Preferred Provider Organizations and American Medical Association have teamed on this joint educational guide on contracting for PPNs, payers and physicians.

Chronic Care Professional Certification—Member Discounts Now Available.

Learn how Chronic Care Professional certification, available at a discount to Care Continuum Alliance members through a special partnership with the HealthSciences Institute, brings valuable benefits to you and your organization. Go >>


Advocacy, research, education and more—the value of Care Continuum Alliance membership is clear. Learn more about who we are and the benefits our corporate and individual members receive.