Chronic Disease Management Strategy

The lack of integration among various silos and inadequate communication among medical providers cause delays in delivering appropriate health care services to our vulnerable patients’ population, mostly the uninsured and underinsured, resulting in poor health outcomes at a high cost. “A strategic plan provides a powerful roadmap to align and navigate organizational activities in pursuit of an impactful and inspiring future vision”.

As a part of my new role in the hospital system and with Managed Medicaid coming to our state, I am tasked to oversee the strategy to create a Chronic Disease Management Center/Clinic that will help to reduce chronic disease burden in the most efficient and cost-effective manner. This is a blend of transitions of care model and integrated model of care for patients with chronic diseases. This is in attempt to avert unnecessary hospitalizations and readmissions, support patients’ preferences and choices, and avoid duplication of services, thereby improving the quality of care while utilizing resources more effectively. I have not been able to rap my head around where or how to begin.

The challenge is, there are many stakeholders (primary care and specialists) who may not buy-in to this program because they already carry out some form of transition of care in their various clinics albeit rather inefficiently but will raise eyebrows since they will lose this segment of TOC revenue should this chronic disease clinic take off. Examples of existing TOC are: Heart Failure Clinic and COPD Gold among others.

Question: What are the critical steps/strategies required to creating and getting enough buy-in to implement a Chronic Disease Management Center/Clinic?

Your inputs are appreciated.


Chronic Disease Management Strategy


Cultural transition from a purely Corporate hospital ———-> corporate + teaching hospital

Participant comments on Chronic Disease Management Strategy

  1. Sometimes when we want to pilot programs that we have little experience in or are concerned that there may be controversy (in provider community), we start with our own employees in our health plan/narrow network. Usually by demonstrating results in that population, we have enough momentum and buy in to then expand.

  2. It would be very beneficial to do a co-create session / value mapping together with key stakeholders around the chronic diseases by putting the patient the in the center. Basically, developing a patient journey around the disease and depicting all care cycle would be presenting the inefficiencies and challenges and would help to break up the silos and buy in from all stakeholders.

  3. I think it is important to establish common ground and also to put ourselves in each of the stakeholders’ shoes to see how we can create a win-win situation. That will then help us in formulating the value proposition. Ultimately, it has to make sense to the stakeholders for them to embrace it. Also, if we are not able to get all stakeholders on board all at once, it is important to build a critical mass to eventually succeed in getting the rest on board.

  4. Some steps I would go through:
    1) First question: what is your organization’s strategy? What are the key pillars and goals to reach? What’s your mission?
    2) Second question then: what’s your key objectives from your chronic disease strategic plan? Again what’s your mission ?
    3) Analyze which link you can set up between the hospital’s strategy and your chronic disease plan. There should be an alignment, a continuity.
    4) Then define cleary the scope of your chronic disease strategic plan:which disease(s) do you wanna cover ? Define the timeframe of your strategic plan. Do you wanna go for a pilot/project roll out mode ? Or a big bang approach with all together? What are your key drivers (quality, cost reduction, growth, patient volume increase, …) ?
    5) Who are the key actors to realize that strategic plan ? Who do you need to involve/have on board to move forward?
    6) I would conduct some AS IS sessions to gather a clear inventory on what’s done today to manage chronic diseases in your institution and then define the gaps between the AS IS situation and where you wanna be tomorrow after realizing your strategic plan (TO BE situation). By identifying those gaps you will be able to define a clear action plan and put some priorities. Those actions car cover different areas: resources from a people perspective, but also infrastructure, technology, innovation, process changes, …
    7) Based on this analyzis I would write down a strategic plan (for 3 to 5 years) + a tactical plan (annuel or bi-annual plan with concrete actions)
    8) I would validate that plan with all key players/stakeholders to have upfront agreement on the plan and the actions you’re gonna conduct all together
    9) Once you get the validation: communicate, communicate, communicate

  5. People frequently are resistant to any sort of changes and this is always a challenge. I recognize benchmarking other institution´s successful programs is always a good way to start – this helps not feeling so lost with a new program creation. Benchmark clinical data is also very valuable, since if you show the healthcare team that their outcomes are poor or not so good as in other institutions in the region or country, this could be a major driver and stimulus for change (people might feel ashamed of their results). This proved to be very successful in the Cystic Fibrosis program at Cincinnati Children’s Hospital we have studied in the second module of MHCD, for example. Lastly, shared earnings (win-win) in this Medicaid program between the healthcare team and the government by reaching better health outcomes and cost reduction could be another incentive for program implementation.

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