Chronic Disease Management Program. Does It Improve Health Outcomes? Preliminary Results

BACKGROUND & PURPOSE: Chronic illness especially cardio-metabolic diseases have had a profound effect on both utilization and cost of health-care. More than 75% of the nation's health-care resources are consumed by chronic disease. A multidisciplinary chronic disease management program is currently being implemented at the Meharry Medical College Family and Community Medicine centers for the management of cardiac and metabolic diseases. The main purpose of this study is evaluation of the effectiveness of this chronic disease care model on health outcomes in patients with cardio-metabolic chronic diseases in an academic setting. DESIGN & METHODS: Patients with chronic cardiac and metabolic diseases have received standardized evidence-based medical care from a physician-led team in a Family Medicine Residency based clinic. The team includes a Family Medicine physician, a nurse practitioner, a social worker, and a nutritionist. The implemented chronic care model is a multidisciplinary system that involves case management, multidisciplinary care, nutritional counseling, life style modification, behavioral intervention and self management. Among many other health outcome measures, baseline levels of low density lipoproteins (LDL), high density lipoproteins (HDL), body mass index (BMI), blood pressure (BP) and hemoglobin A1C (HbA1c) have been collected at the time of enrollment into the program. These outcomes have been assessed at three, six and nine month post-enrollment and compared to the pre-enrollment baseline levels. RESULTS: Up to date, about two hundred patients with chronic cardiac and metabolic diseases are enrolled into Meharry Family Medicine Chronic Disease Management Program. Preliminary analysis of data shows that there are significant differences between pre-enrollment baseline levels of HbA1C, body weight, and LDL and those measured at 6-9 month post-enrollment (p< 0.0001, 0.05, and 0.01; respectively). The pre-enrollment mean and standard deviation were 8.1% + 2.2, 223.3 lb + 57.7 and 108.0 mg/dL + 42.5 for HbA1C, body weight, and LDL; respectively. However, the 6-9 post-enrollment mean and standard deviation were 7.1% + 1.9, 211.7 lb + 46.1 and 95.8 mg/dL + 331.1 for HbA1C, body weight, and LDL; respectively. CONCLUSION: Implementing chronic disease management care model in primary care setting improves health outcomes in patients with cardiac and metabolic diseases. Our goal is to expand this program to recruit more patients, and evaluate other health outcome measures. It is our goal also to imply this model of care to patients with other chronic diseases such as asthma and COPD. Research supported by Health Resources and Service Administration (HRSA) Grant # D54MP05469.