diseasemanagement

Disease management is a systematic, patient-centered approach to coordinating care for people with chronic conditions in order to improve health outcomes and reduce unnecessary health care utilization. It relies on proactive identification of at-risk patients, standardized care processes, and ongoing monitoring across settings, guided by evidence-based guidelines.

Core elements include risk stratification to identify high-need individuals, individualized care plans, self-management support, medication management, regular status tracking, and care coordination across primary, specialty, and community services. Data collection and feedback loops support continuous quality improvement and accountability.

Methods and tools commonly used in disease management include multidisciplinary care teams (such as nurses, physicians, and pharmacists), patient education, remote monitoring and telehealth, electronic health records, patient registries, and analytics to guide decision-making and measure outcomes.

Common targets and programs cover chronic diseases such as diabetes, cardiovascular disease, hypertension, COPD, asthma, and chronic kidney disease. Programs may also address transitions of care, polypharmacy, and aspects of palliative or survivorship care as appropriate to the condition and setting.

Evidence and considerations indicate that well-implemented disease management can reduce hospital admissions, emergency department visits, and medication nonadherence, while improving patient-reported outcomes. Effectiveness depends on program design, patient engagement, and integration with primary care, as well as upfront investments in data infrastructure and care coordination capabilities.

Challenges include variability in program models, social determinants of health, health literacy, privacy and interoperability of health information systems, and ensuring equity within value-based care models.