Health education and risk stratification methods to increase engagement in and improve population health outcomes from chronic disease management interventions

Background: Most disease management programs engage employees in telephonic or online behavior change support that is general to the population, but is not tailored to individual risk. Predictive-modeling literature confirms that risk stratification is important, yet there is a paucity of evidence in disease management literature that confirms the effectiveness of interventions based on risk severity. This study examines the effectiveness of a telephonic disease management program that stratifies patients by risk level, provides tailored health education by registered nurse health coaches, and engages physicians for consistency and quality of care. Methods: Local business employees with chronic disease were identified and stratified into low, moderate, and high-risk categories of disease severity based on their propensity for morbidity. The Health Belief and Diffusion of Innovations Models guided individual interventions, educational materials, physician engagement, and motivational interviewing techniques. Results: Results of this study are currently in progress. Preliminary results show that employee engagement in the disease management program in calendar year 2010 increased 90% from year 2009. Clinical outcome and behavior change indicators may potentially show increased enrollment and completion of the disease management program, improved lab values, medication adherence, compliance with preventive care, and improved self-reported behavior changes assessed by the program nurse coaches. Conclusion: Implementing individual morbidity risk stratification and subsequent risk-based health education interventions in disease management programs may result in improved population health outcomes.