Chronic disease management: a Singapore perspective
BMJ 2001; 323 doi: https://doi.org/10.1136/bmj.323.7319.990 (Published 27 October 2001) Cite this as: BMJ 2001;323:990Data supplement
Disease management The Disease Management Association of America’s (DMAA) definition of disease management
A multidisciplinary, continuum based approach to healthcare delivery that proactively identifies populations with, or at risk of established medical conditions, that:
· Supports the physician-patient relationship and plan of care · Emphasises prevention of exacerbations and complications utilising cost effective evidence based practice guidelines and patient empowerment strategies such as self-management
· Continuously evaluates clinical, humanistic, and economic outcomes with the goal of improving overall health The scope for any chronic disease management programme should contain the following:
· Population identification process · Evidence based clinical practice guidelines/pathways
· Collaborative practice model to include clinician and support-service providers
· Risk identification and matching of interventions with patient need
· Patient self-management and education (may include primary prevention, behaviour modification programmes, and adherence)
· Process and outcomes measurement, evaluation, and management
· Routine reporting of clinical quality indicators with feedback loop (may include communication with patient, doctor, healthcare purchaser, and ancillary providers)
· Appropriate use of information technology (may include specialised software, clinical data registries, automated decision support tools, and call back systems)
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- Editorial Published: 27 October 2001; BMJ 323 doi:10.1136/bmj.323.7319.947
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